Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania

1. Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania Suzanne Maman Health Behavior and Health Education Thank you for this opportunity to start out the office of global health monthly seminar series for this academic year. I have seen the list of other speakers scheduled in the series, and I am honored to be the first in the series of what looks like an exciting panel of speakers. I would like to use this opportunity today to share with you some work that I am currently engaged in with colleagues in Dar es Salaam, Tanzania focused on HIV and violence prevention with youth, young men in particular. Thank you for this opportunity to start out the office of global health monthly seminar series for this academic year. I have seen the list of other speakers scheduled in the series, and I am honored to be the first in the series of what looks like an exciting panel of speakers. I would like to use this opportunity today to share with you some work that I am currently engaged in with colleagues in Dar es Salaam, Tanzania focused on HIV and violence prevention with youth, young men in particular.

2. Before I begin to describe some of the work that we are doing with young men, I thought it would be helpful to give a little background to give you an idea of how we ended up working with young men on the intersecting epidemics of HIV and violence. There is now evidence for at least four ways in which the epidemics of HIV and violence intersect in the lives of women. In terms of violence as a risk factor for HIV, there is evidence that women in violent relationships are less able to enforce HIV preventive behaviors. From research among AA women here in the U.S. Wingood and Diclemente showed that women with abusive partners are more likely to report never using condoms and are more likely to report being abused when asking partners to use a condom. Second, there is evidence that women who have experienced physical and sexual abuse engage in more HIV risk behaviors. From work by Jewkes and colleagues in South Africa they found that early sexual violence was associated with early sexual debut, trading sex for money, and more sexual partners. From Uganda Koenig found that women who report that their first sex was coercive face HIV risks almost twice as high as women who report that their first sex was not coercive. Third, there is evidence that the biological trauma from forced sex may facilitate HIV transmission. From research by Campbell and colleagues here in the U.S. it has been shown that forced sex is associated with anal and vaginal tearing, vaginal bleeding, and UTIs. Wingood also found that women reporting sexual abuse were 4 times more likely to have multiple STDs compared to women who report physical abuse along. Finally, there is some evidence on the link between violence and women�s experiences with HIV serostatus disclosure. Violence is a major barrier to disclosure among HIV-infected women, however there is little evidence that women who disclose are at elevated risk of violence. Before I begin to describe some of the work that we are doing with young men, I thought it would be helpful to give a little background to give you an idea of how we ended up working with young men on the intersecting epidemics of HIV and violence. There is now evidence for at least four ways in which the epidemics of HIV and violence intersect in the lives of women. In terms of violence as a risk factor for HIV, there is evidence that women in violent relationships are less able to enforce HIV preventive behaviors. From research among AA women here in the U.S. Wingood and Diclemente showed that women with abusive partners are more likely to report never using condoms and are more likely to report being abused when asking partners to use a condom. Second, there is evidence that women who have experienced physical and sexual abuse engage in more HIV risk behaviors. From work by Jewkes and colleagues in South Africa they found that early sexual violence was associated with early sexual debut, trading sex for money, and more sexual partners. From Uganda Koenig found that women who report that their first sex was coercive face HIV risks almost twice as high as women who report that their first sex was not coercive. Third, there is evidence that the biological trauma from forced sex may facilitate HIV transmission. From research by Campbell and colleagues here in the U.S. it has been shown that forced sex is associated with anal and vaginal tearing, vaginal bleeding, and UTIs. Wingood also found that women reporting sexual abuse were 4 times more likely to have multiple STDs compared to women who report physical abuse along. Finally, there is some evidence on the link between violence and women�s experiences with HIV serostatus disclosure. Violence is a major barrier to disclosure among HIV-infected women, however there is little evidence that women who disclose are at elevated risk of violence.

3. The evidence on the links between HIV and violence is growing. A publication in Lancet from South Africa demonstrated that women with violent partners have a more than 50% increased risk of acquiring HIV. From a study we conducted in Tanzania, we found that the odds of reporting violence was ten times higher for young, HIV-positive women as compared to young, HIV negative women. The evidence on the links between HIV and violence is growing. A publication in Lancet from South Africa demonstrated that women with violent partners have a more than 50% increased risk of acquiring HIV. From a study we conducted in Tanzania, we found that the odds of reporting violence was ten times higher for young, HIV-positive women as compared to young, HIV negative women.

4. Rationale for working with young men Men are generally perpetrators of gender-based violence Men control the terms & conditions of sexual relationships Very little is understood about the attitudes and behaviors of young men in this context Young men lack access to information and services Adolescence is a time when lifelong patterns are formed Given the strong link between HIV status and women�s history of violence among young women we interviewed in Tanzania, we decided our next step would be to turn our focus to young men. We know that men are generally the perpetrators of gender-based violence. We also know that men generally control the terms and conditions of their sexual relationships. There has been very little research conducted on young men in general, and in Tanzania in particular. The literature also suggests that young men are a population that is often overlooked in terms of information and services. Finally, our decision to focus on young men as opposed to older adult men is that we felt if we could intervene during adolescence we may be able to influence lifelong patterns of behavior. Given the strong link between HIV status and women�s history of violence among young women we interviewed in Tanzania, we decided our next step would be to turn our focus to young men. We know that men are generally the perpetrators of gender-based violence. We also know that men generally control the terms and conditions of their sexual relationships. There has been very little research conducted on young men in general, and in Tanzania in particular. The literature also suggests that young men are a population that is often overlooked in terms of information and services. Finally, our decision to focus on young men as opposed to older adult men is that we felt if we could intervene during adolescence we may be able to influence lifelong patterns of behavior.

5. So we designed an intervention study for young men called the Tuelemishane Project in Dar es Salaam, Tanzania. This is an intervention designed to reduce HIV risk and reported use of violence among young men using a combination of peer support and community theatre. So we designed an intervention study for young men called the Tuelemishane Project in Dar es Salaam, Tanzania. This is an intervention designed to reduce HIV risk and reported use of violence among young men using a combination of peer support and community theatre.

6. The study was carried out in Tanzania which is on the east coast of Africa, south of Kenya and Uganda and North of Malawi and Zambia. Tanzania is the largest of the East African countries. Within Tanzania we were based in Dar es Salaam, which is the commercial capitol located on the sores of the Indian Ocean. Tanzania has a population of 32 million million of whom 3-4 million a are located in Dar es Salaam. It is estimated that 50% of the population lives below the poverty level. The annual per capita GNP isestimated at US $246. The study was carried out in Tanzania which is on the east coast of Africa, south of Kenya and Uganda and North of Malawi and Zambia. Tanzania is the largest of the East African countries. Within Tanzania we were based in Dar es Salaam, which is the commercial capitol located on the sores of the Indian Ocean. Tanzania has a population of 32 million million of whom 3-4 million a are located in Dar es Salaam. It is estimated that 50% of the population lives below the poverty level. The annual per capita GNP isestimated at US $246.

7. The intervention consists of two major components. Through the peer support component we have enrolled men in groups of 10-12 members. The groups meet monthly for a 12-month period and the 2 hour sessions are facilitated by trained peer group leaders. The peer groups are complemented by a community theatre component. We have trained a group of youth in Dar to perform interactive skits that our team developed, with the youth. The performances are held in community-based venues that are frequented by young men. We created 3 different skits that focus on key themes that emerged from our formative phase including infidelity, conflict and respect. There will be a total of 12 performances in the intervention community. The intervention consists of two major components. Through the peer support component we have enrolled men in groups of 10-12 members. The groups meet monthly for a 12-month period and the 2 hour sessions are facilitated by trained peer group leaders. The peer groups are complemented by a community theatre component. We have trained a group of youth in Dar to perform interactive skits that our team developed, with the youth. The performances are held in community-based venues that are frequented by young men. We created 3 different skits that focus on key themes that emerged from our formative phase including infidelity, conflict and respect. There will be a total of 12 performances in the intervention community.

8. To develop the intervention we conducted a 9-month formative phase in which we conducted in-depth interviews and focus group discussions with young men and women. The data from the formative phase fed directly into both the peer group and the drama intervention content. To evaluate the intervention we have interviewed 475 young men in the intervention community and 475 young men in the control community at baseline. Two months after the intervention is complete, we will re-interview these same men for our post-intervention assessment. The quantitative evaluation will be complemented by a small qualitative component in which we will conduct in-depth interviews with the female partners of 40 of the men who have been enrolled in the intervention, to hear from their perspective whether they have noted any changes in the attitudes or behaviors of their male partners. To develop the intervention we conducted a 9-month formative phase in which we conducted in-depth interviews and focus group discussions with young men and women. The data from the formative phase fed directly into both the peer group and the drama intervention content. To evaluate the intervention we have interviewed 475 young men in the intervention community and 475 young men in the control community at baseline. Two months after the intervention is complete, we will re-interview these same men for our post-intervention assessment. The quantitative evaluation will be complemented by a small qualitative component in which we will conduct in-depth interviews with the female partners of 40 of the men who have been enrolled in the intervention, to hear from their perspective whether they have noted any changes in the attitudes or behaviors of their male partners.

9. Formative and Baseline Findings The formative and baseline phase of the intervention study is complete and I would like to share with you some of our findings from these phases. The formative and baseline phase of the intervention study is complete and I would like to share with you some of our findings from these phases.

10. From the formative phase we learned a lot about the social context of adolescent relationships in this setting. Based on our analysis of both the in-depth interviews and the focus group discussions we identified some key themes that we felt describe key elements of adolescent relationships. First, it was clear that intimate relationships revolve almost exclusively around sexual activity. Men and women said that to love a partner one must be willing to have sex. As described by one of our male key informants. There were very few examples of friendships between men and women that did not involve sexual activity. From the formative phase we learned a lot about the social context of adolescent relationships in this setting. Based on our analysis of both the in-depth interviews and the focus group discussions we identified some key themes that we felt describe key elements of adolescent relationships. First, it was clear that intimate relationships revolve almost exclusively around sexual activity. Men and women said that to love a partner one must be willing to have sex. As described by one of our male key informants. There were very few examples of friendships between men and women that did not involve sexual activity.

11. Another major theme that jumped out from the youth�s description of their relationships was a deep level of mistrust between partners. The mistrust largely revolved around concerns about infidelity. Youth described little emotional or romantic love in their relationships. Mistrust stemmed from fear of infidelity on the part of young women and men�s concerns about women�s financial motives. Multiple partnerships were common and were openly discussed by young men and some young women. Infidelity was also the most common trigger for violence mentioned by women. Another major theme that jumped out from the youth�s description of their relationships was a deep level of mistrust between partners. The mistrust largely revolved around concerns about infidelity. Youth described little emotional or romantic love in their relationships. Mistrust stemmed from fear of infidelity on the part of young women and men�s concerns about women�s financial motives. Multiple partnerships were common and were openly discussed by young men and some young women. Infidelity was also the most common trigger for violence mentioned by women.

12. The mistrust that seemed to underlie adolescent relationships was also related to the transactional nature of relationships. In virtually all relationships there was an expectation of money or gifts from male partners to female partnership. Young women described measuring the degree of men�s love/commitment by the gifts that they provided. There were some women who engaged in sexual relationships out of financial need�though I would say that this was the minority of cases. Concerns over financial motivations of women was the primary trigger for violence mentioned by men. The mistrust that seemed to underlie adolescent relationships was also related to the transactional nature of relationships. In virtually all relationships there was an expectation of money or gifts from male partners to female partnership. Young women described measuring the degree of men�s love/commitment by the gifts that they provided. There were some women who engaged in sexual relationships out of financial need�though I would say that this was the minority of cases. Concerns over financial motivations of women was the primary trigger for violence mentioned by men.

13. The language that youth use to describe their relationships reflect the mistrust Pulling the load (Anavuta mzigo) Men describe taking on new girlfriends as pulling the load Skinning the goat (Kuchuna buzi) Women describe strategies to extract money from their partners as skinning the goat From our qualitative interviewed, we noted that the language used to describe partnerships reflected this general level of mistrust between the sexes. For example, young men described taking on new female partners as Anavuta mzigo, or pulling the load. Referring to the financial drain that women present to the men. Women on the other hand used language to show that they do have some agency in the process. They used the term, kuchuna buzi, or skinning the goat to describe the strategies that they use to extract money from their partners. Neither of these terms reflected a deep respect or compassion for their sexual partners. And I think this is the feeling we ended with in our qualitative analysis�that the sexual partnerships of youth were not built on foundations of respect and care. From our qualitative interviewed, we noted that the language used to describe partnerships reflected this general level of mistrust between the sexes. For example, young men described taking on new female partners as Anavuta mzigo, or pulling the load. Referring to the financial drain that women present to the men. Women on the other hand used language to show that they do have some agency in the process. They used the term, kuchuna buzi, or skinning the goat to describe the strategies that they use to extract money from their partners. Neither of these terms reflected a deep respect or compassion for their sexual partners. And I think this is the feeling we ended with in our qualitative analysis�that the sexual partnerships of youth were not built on foundations of respect and care.

14. Conservative attitudes regarding gender norms and expectations 69% of men agreed that men should have final say in all family matters 48% felt women should tolerate being beaten to keep family together 44% felt if women want to leave abusive partner they must leave children behind From the baseline quantitative survey we conducted with the 950 men we found that these young men held very conservative attitudes regarding gender norms and expectations. Nearly two thirds of men agreed that men should have final say in all family matters. Almost half felt that women should tolerate being beaten to keep the family together and similarly almost half felt that if a woman wanted to leave an abusive husband she would need to leave her children behind. From the baseline quantitative survey we conducted with the 950 men we found that these young men held very conservative attitudes regarding gender norms and expectations. Nearly two thirds of men agreed that men should have final say in all family matters. Almost half felt that women should tolerate being beaten to keep the family together and similarly almost half felt that if a woman wanted to leave an abusive husband she would need to leave her children behind.

15. Experiences with violence in childhood were common 11% reported unwanted sexual touching or intercourse under the age of 12 years 43% reported experiencing serious physical violence as a child 28% reported witnessing their father physically assault their mother We asked about men�s own experiences with abuse in their childhood. 11% reported being touched or being forced into intercourse under the age of 12 years, Almost half reported experiencing serious physical violence as a child and over a quarter reported witnessing their father physically assault their mother when they were growing up. We asked about men�s own experiences with abuse in their childhood. 11% reported being touched or being forced into intercourse under the age of 12 years, Almost half reported experiencing serious physical violence as a child and over a quarter reported witnessing their father physically assault their mother when they were growing up.

16. Young men describe substantial HIV risk 70% of men were sexually active and the mean age of first sex was 16 years (SD 2.90 years) The mean number of lifetime partners was 3.96 (SD 5.55) 47% reported having had sex without a condom in the past 6 months Despite awareness and knowledge of HIV and despite high perceived risk of HIV, young men continue to describe substantial HIV risk. 70% of the men we interviewed who were sexually active and the mean age at first sex was 16 years, which is very consistent with other studies reported in the literature. The mean number of lifetime partners was almost 4, though there was a wide range between X and X. Nearly a third of the men reported that they had used a condom during their first sexual encounter, but almost half of sexually active men reported unprotected sex in the past 6-months. Despite awareness and knowledge of HIV and despite high perceived risk of HIV, young men continue to describe substantial HIV risk. 70% of the men we interviewed who were sexually active and the mean age at first sex was 16 years, which is very consistent with other studies reported in the literature. The mean number of lifetime partners was almost 4, though there was a wide range between X and X. Nearly a third of the men reported that they had used a condom during their first sexual encounter, but almost half of sexually active men reported unprotected sex in the past 6-months.

17. Use of physical violence against female partners was high Among sexually active men, 30% reported at least one episode of physical violence with a partner 9% reported using physical violence to force a partner to have sex 5% reported reacting violently when a partner refused to have sex When we asked about the use of physical violence against female partners, 30% of men reported at least one episode of violence. 9% reported using physical violence to force a partner into having sex against her will and 5% reported reacting violently when a partner refused to have sex. When we asked about the use of physical violence against female partners, 30% of men reported at least one episode of violence. 9% reported using physical violence to force a partner into having sex against her will and 5% reported reacting violently when a partner refused to have sex.

18. Factors associated with the use of physical violence Number of sexual partners Men with 4-10 lifetime partners had 5 X greater odds of reporting violence (95% CI: 2.6-10.4) Men with 2 or more partners in the past 6-months had 2 X greater odds of reporting violence (95% CI: 1.19-4.56) Pressure from peers to have sex The odds of reporting violence was 2.5 X higher among men who report moderate pressure from peers to have sex (95% CI: 1.30-4.99) Childhood physical abuse The odds of reporting violence was 2 X greater for men who experienced physical violence in childhood (95% CI: 1.42-3.33) We conducted a multivariate analysis to identify the individual, relational and environmental factors associated with the use of physical violence. The dependent outcome in this analysis is the report of at least one physically violent event with a partner ever. We found an association between HIV risk behaviors and violence. Men who reported more lifetime partners and men who reported more partners in the past 6-months had a 2-5 times greater odds of reporting violence. Pressure from peers also emerged as a factors associated with the use of violence. Men who reported moderate pressure from peers to have sex had a higher odds of reporting violence. Finally, men who reported that they had experienced severe physical violence as a child had a two fold greater odds of reporting violence with their partners. We conducted a multivariate analysis to identify the individual, relational and environmental factors associated with the use of physical violence. The dependent outcome in this analysis is the report of at least one physically violent event with a partner ever. We found an association between HIV risk behaviors and violence. Men who reported more lifetime partners and men who reported more partners in the past 6-months had a 2-5 times greater odds of reporting violence. Pressure from peers also emerged as a factors associated with the use of violence. Men who reported moderate pressure from peers to have sex had a higher odds of reporting violence. Finally, men who reported that they had experienced severe physical violence as a child had a two fold greater odds of reporting violence with their partners.

19. Conclusions So what are some of the conclusions that we drew from the data�..So what are some of the conclusions that we drew from the data�..

20. Despite being two decades into epidemic, youth are still at risk 8.8% of Tanzanians are HIV infected nationally 60% new infections occur among 16-24 yr olds Multiple partnerships were common Unprotected sexual intercourse was common First, despite being two decades into the epidemic it is very clear that youth are still at risk for HIV. The national prevalence rates in Tanzania are 8.8%. 60% of all new infections occur among 16-24 year olds. And among youth, women are 6 times more likely to get infected than men. From our data it was quite clear that the behaviors that place youth at risk continue. Multiple partnerships were described by many youth and unprotected sexual intercourse was common. First, despite being two decades into the epidemic it is very clear that youth are still at risk for HIV. The national prevalence rates in Tanzania are 8.8%. 60% of all new infections occur among 16-24 year olds. And among youth, women are 6 times more likely to get infected than men. From our data it was quite clear that the behaviors that place youth at risk continue. Multiple partnerships were described by many youth and unprotected sexual intercourse was common.

21. Men control the sexual decision making in relationships Men describe conservative attitudes related to sexual norms and expectations Women have limited agency in the process of initiating and maintaining partnerships It was also clear, particularly from our qualitative data, that men continue to control the terms and conditions of their sexual relationships. We were struck by how conservative this group of young men were regarding attitudes towards sexual norms and expectations. Women described some strategies they use to exert control in their relationships, but these efforts were very limited. It was also clear, particularly from our qualitative data, that men continue to control the terms and conditions of their sexual relationships. We were struck by how conservative this group of young men were regarding attitudes towards sexual norms and expectations. Women described some strategies they use to exert control in their relationships, but these efforts were very limited.

22. The socioeconomic context plays a role in the formation and dynamics of sexual relationships Women engage in sexual relationships to achieve financial support The transactional nature of relationships leave women vulnerable to both HIV risk and violence The socioeconomic context in which these youth live clearly plays a role in the formation and dynamics of sexual partnerships. In a setting where the annual GNP is less than $300 a year, it was clear that there were some women who engaged in sexual relationships to achieve some financial support. Even if it was not sex for survival, the transactional nature of relationships, the exchanging of money and gifts, leave women vulnerable to both HIV risk and violence. The socioeconomic context in which these youth live clearly plays a role in the formation and dynamics of sexual partnerships. In a setting where the annual GNP is less than $300 a year, it was clear that there were some women who engaged in sexual relationships to achieve some financial support. Even if it was not sex for survival, the transactional nature of relationships, the exchanging of money and gifts, leave women vulnerable to both HIV risk and violence.

23. There were clear associations between HIV and violence Men with more sexual partners report using violence more often Infidelity was the trigger for violence mentioned most often by women The links between HIV and violence that we described in our earlier work with women was corroborated in this study among young men. Men who report more sexual partnerships reported using violence more often. Infidelity and suspicions of infidelity was the major trigger for violence. The links between HIV and violence that we described in our earlier work with women was corroborated in this study among young men. Men who report more sexual partnerships reported using violence more often. Infidelity and suspicions of infidelity was the major trigger for violence.

24. Tuelemishane Project Moves us out of the clinic into the community, and shifts the focus from women to men Designed to give men space to talk about norms surrounding sexual behavior and conflict. Through a 1-year intervention we hope to see some changes in attitudes and norms�and optimistically behaviors. We used some of this data from the formative phase to help us tailor our intervention. The intervention we designed was an attempt for our group to move out of the clinic and into the community and to shift our focus grou women to young men. The intervention is designed to give men the space to talk about norms surrounding sexual behavior and conflict. Through the 1-year intervention we hope to see some changes in attitudes and norms and optimistically behaviors. We used some of this data from the formative phase to help us tailor our intervention. The intervention we designed was an attempt for our group to move out of the clinic and into the community and to shift our focus grou women to young men. The intervention is designed to give men the space to talk about norms surrounding sexual behavior and conflict. Through the 1-year intervention we hope to see some changes in attitudes and norms and optimistically behaviors.

25. Where do we go from here? One approach is not sufficient Multi-level interventions are needed The challenge is to reach men where they spend time & to keep them engaged Venue-based interventions Younger men need to be the focus of our interventions We are not na�ve enough to realize that one approach is sufficient to deal with these issues. Clearly interventions or combination of interventions that address determinants on multiple levels including individual, relational, and structural are needed. We have been challenged by how to keep men engaged in the intervention. Approaches that reach men where they spend time may be one effective way to keep men engaged. Finally, it was clear from our baseline data that many of the attitudes and behaviors related to both HIV and violence are well established by the time young men reach the age of 16. This tells us that we need to think about strategies to work with younger men. It seems like there are enormous barriers to working with very young on sensitive topics such as HIV and violence, but if we really want to shift norms and behaviors before they become too established we need to think about approaches to overcome these barriers. We are not na�ve enough to realize that one approach is sufficient to deal with these issues. Clearly interventions or combination of interventions that address determinants on multiple levels including individual, relational, and structural are needed. We have been challenged by how to keep men engaged in the intervention. Approaches that reach men where they spend time may be one effective way to keep men engaged. Finally, it was clear from our baseline data that many of the attitudes and behaviors related to both HIV and violence are well established by the time young men reach the age of 16. This tells us that we need to think about strategies to work with younger men. It seems like there are enormous barriers to working with very young on sensitive topics such as HIV and violence, but if we really want to shift norms and behaviors before they become too established we need to think about approaches to overcome these barriers.

26. Acknowledgements Funding: The intervention is funded through a grant from USAID, Interagency Gender working group. The research is funded by The Population Council Horizons Project. Co-Investigators J. Mbwambo, (Muhimbili); M. Sweat, H.Lary (JHU), M. Roche (UNC); F. Kouyoumdjian (Toronto) Research Staff: R. Kaballa, A. Mwampashi, L. Sabuni, E. Kakwezi, U. Peter, L. Ezekiel, E. Chezi, H. Marijani and J. Donath.