Gender and Multiple and Concurrent Sexual Partnerships in Zambia

1. Gender and Multiple and Concurrent Sexual Partnerships in Zambia Preliminary Findings Tropical Diseases Research Center Uniting the world against AIDS National AIDS Council

2. Study Contributors Project Investigator Shepherd Khondowe, TDRC NAC Steering Committee Harold Witola, NAC Kathleen MacQueen, FHI US Michael Gboun, UNAIDS Florence Mulenga, UNFPA Katy Barwise, IOM Sansan Myint, UNICEF Kanyanta Sunkutu, WHO Steve Sichone, FHI ZA Technical Monitor Catalina Ramirez, FHI US Study Partners National Aids Council (NAC) United Nations (UNAIDS,UNICEF, UNFPA, WHO) Family Health International (FHI) International Organization for Migration (IOM) Tropical Diseases Research Center (TDRC) Funders United Nations (UNAIDS,UNICEF, UNFPA) International Organization for Migration (IOM) United States Agency for International Development (USAID) National AIDS Council (NAC) Concurrency in Zambia 2010

3. NAC Dr. Ben Chirwa Dr. Osward Mulenga MCP Steering Committee Members United Nations Dr. Amaya Gillespie IOM Joseph Ongina Annie Lane FHI Cathy Thompson Mark Weaver Kathryn Lancaster TDRC Dr. Modest Mulenga Nancy Soko Research Assistants Acknowledgements Concurrency in Zambia 2010

4. Presentation Outline • Introduction Study Rationale Research Questions • Methods Population / Site Selection Community Engagement Data Collection Procedures Analysis • Results In-depth Interview Calendar Data Focus Groups • Summary Limitations and Strengths Conclusions Next Steps Concurrency in Zambia 2010

5. INTRODUCTION

6. Background: MCP and HIV • UNAIDS Reference Group on Estimates, Modelling, and Projectionsmeeting, Nairobi 2009 • CONCLUSION: Standardized new measure on concurrency (“overlapping concurrency”). • Emphasized need for research into the methods of measuring concurrent partnerships and sexual behaviour, the relationship between concurrency and HIV transmission, and social norms around concurrent partnerships. • Southern African Development Community meeting, Maseru 2006 • CONCLUSION: multiple concurrent sexual partners is one of the key drivers of the epidemic in the Southern African region Concurrency in Zambia 2010

7. MCP in Zambia; ZDHS 2007 • 2 % women and 20% of men between 15-49 reported sex with two or more partners in the 12 months before the survey. • 17% of women and 38% of men reported that they had sex in the previous 12 months with someone who was not their spouse. Concurrency in Zambia 2010 Unit 8: Protocol Overview Multiple and Concurrent Partnerships in Zambia

8. Previous Research • Important formative research was conducted by the Health Communication Partnership (HCP), Society for Family Health (SFH) and Zambia Center for Communication Programmes (ZCCP). • Informed the OneLove, Kwasila! campaign which rolled-out in May 2009 • Focus group results were used by current study to inform cultural model and perceptions surrounding concurrency. • No contemporary qualitative study is available exploring the practice of having multiple concurrent sexual partners within the context of stable relationships in Zambia Concurrency in Zambia 2010

9. Study Rationale • Little is known about how best to reduce HIV risk among men and women In stable relationships AND In concurrent partnerships • Programmes need to respond to sexual relationships as they exist actual gender ideas social values cultural meanings Concurrency in Zambia 2010

10. Study Objectives • OBJECTIVE 1: Generate context-specific information on the practice of multiple concurrent sexual partnerships in the context of stable relationships. • OBJECTIVE 2: Highlight community perceptions and understanding of HIV risk within stable relationships in order to strengthen community and civil society communication and advocacy for social change. • OBJECTIVE 3: Strengthen evidence-based community dialogue on HIV prevention within stable relationships, particularly through improved mechanisms for involvement of men in dialogue and community response. • OBJECTIVE 4: To add to and strengthen the monitoring systems that track behavioural trend data which influence the epidemic in Zambia as a basis for informing HIV/ADS programs. Concurrency in Zambia 2010

11. OBJECTIVE 1: Generate context-specific information on the practice of multiple concurrent sexual partnerships in the context of stable relationships. • RESEARCH Q1: What are the social norms of stable relationships among men and women? • RESEARCH Q2 What are the values and obligations associated with these relationships? • RESEARCH Q3: What is the value of sex among men and women? • What are the structures/systems that promote/sustain these values? • Are there social benefits or constraints that make MCP relations difficult to terminate? • RESEARCH Q4: What are the structures/systems that promote/sustain multiple and concurrent sexual partnerships? • RESEARCH Q5: Are there economic factors that encourage and sustain MCP in both genders? • RESEARCH Q6: What are the life experiences of men and women with regard to multiple and concurrent sexual partnerships in the context of stable relationships? Concurrency in Zambia 2010

12. OBJECTIVE 2: Highlight community perceptions and understanding of HIV risk within stable relationships in order to strengthen community and civil society communication and advocacy for social change. • RESEARCH Q7: How is HIV risk perceived and negotiated within stable and concurrent relationships? • RESEARCH Q8: What can be done to encourage people to reduce their risk of HIV infection? Concurrency in Zambia 2010

13. OBJECTIVE 3: Strengthen evidence-based community dialogue on HIV prevention within stable relationships, particularly through improved mechanisms for involvement of men in dialogue and community response. • RESEARCH Q1: What are the social norms of stable relationships among men and women? • RESEARCH Q3: What is the value of sex among men and women? • RESEARCH Q7: How is HIV risk perceived and negotiated within stable and concurrent relationships? • RESEARCH Q8: What can be done to encourage people to reduce their risk of HIV infection? Concurrency in Zambia 2010

14. Ethics Review & Approval • Tropical Diseases Research Ethics Committee, TDRC • Ndola, Zambia • Protection of Human Subjects Committee, FHI • Durham, North Carolina Tropical Diseases Research Centre, Ndola Zambia Concurrency in Zambia 2010

15. METHODS

16. Methods: Population & Site Selection Concurrency in Zambia 2010

17. TDRC 1Principal Investigator 1 Study Coordinator 9 Researcher Assistants 2 Data Entry Staff FHI 1 Study Manager Methods: In- Country Data Team Concurrency in Zambia 2010

18. Community Engagement • PURPOSE: Elicit acceptance for the project at each potential site. • Introduce the study • Identify stakeholders and how/where they can be located. • Gain approvals from key stakeholders • Assess acceptability and viability of the study • Learn about possible strategies of resolving implementation challenges • Identify catchment areas for the target populations • Led by Study Manager and Study Coordinator in partnership with National AIDS Commission (NAC) • Support and Coordination by : District AIDS Task Force (DATF), Provincial AIDS Task Force (PATF), Provincial AIDS Coordination Advisor (s) (PACA) and District AIDS Coordination Advisor(s) (DACA) Concurrency in Zambia 2010

19. Community Engagement: Methods • Key informant interviews with Traditional Leaders and other Community Leader(s) • 4-5 per site • To elicit recruitment strategy • Stakeholder meetings held at District level • 2-3 per site • To inform about study • To get initial input on perceptions about HIV in the community • 1 FGDs conducted at each site (7 total; approx.70 participants) • 1 stakeholder, mixed gender and age • To supplement previous research Concurrency in Zambia 2010

20. Community Engagement: Methods • Approvals to go forward obtained from • MOH • NAC • DATF/PATF • Traditional Leader(s) • District Health Office • District Commissioner • Local Authorities Concurrency in Zambia 2010

21. In-depth interviews (IDI) Specific sexual partnerships/behavior and related social, cultural, and behavioral practices Data Collection Overview Concurrency in Zambia 2010

22. In-depth Interviews • People in stable partnerships (self-defined) • Purposive selection for diversity of gender, age, marital status, and socioeconomic status • Local guidance sought at each site for how to recruit for diversity • 301 total IDIs conducted at 7 sites Concurrency in Zambia 2010

23. In-depth Interviews • Key Areas of Interest • Sexual History • Relationship Status • Migration/Mobility • Partners (past 12 mos) • Perceived closeness of each partner • HIV Knowledge/ Attitudes Concurrency in Zambia 2010

24. IDI: Data Collection Tools • Visualize relationships (sociogram) • How many partners? • How well do you know each partner? • How well do your partners know each other? • Partner characteristics • Sexual activity recall (time-line follow-back) • Use of memory aids • 1-year recall • For each month • First & last day of sex with each partner • Frequency of sex with each partner Concurrency in Zambia 2010

25. IDI: Data Collection Tools Concurrency in Zambia 2010

26. ANALYSIS

27. Analysis Strategy: Text Data • Capture key ideas, themes and concepts (content coding) • FHI US data team worked with in-country field team to identify themes. • Detailed code definitions developed • Code all text using content code book • 2 FHI coders • Intercoder agreement checks Concurrency in Zambia 2010

28. Example of Content Code Concurrency in Zambia 2010

29. Analysis Strategy: Partner Data • Quantitative Data • Sociogram • Calendar • Partner Characteristics • Length of Partnership • Mobility/ Migration • Other Partnerships • HIV Risk • Generate output to describe • Types of partnerships • Frequencies of types Concurrency in Zambia 2010

30. Definitions: Calendar Data Concurrency in Zambia 2010

31. Definitions: Calendar Data Concurrency in Zambia 2010

32. Preliminary Results

33. Quantitative Data Results

34. Calendar Data Results *information missing for 6 participants Concurrency in Zambia 2010

35. Calendar Data Results *information missing for 6 participants Concurrency in Zambia 2010

36. Calendar Data Results *information missing for 12 participants Concurrency in Zambia 2010

37. Calendar Data Results Concurrency in Zambia 2010

38. Calendar Data Results Nine interviews were missing age information Concurrency in Zambia 2010

39. “Multiple Partners”: Perceptions vs. Actual Behavior • When asked directly if they ever had more than one partner at a time, 7 men and 23 women, of the 136 preliminary interviews analyzed, said no. • TLFB method indicated 4 of the 7 men and 8 of the 23 women identified overlapping concurrent partners in the previous 12 months. • Qualitative data indicated that the phrase “multiple partners” is often interpreted as partners with whom the participant had sex close in time (e.g., one week) or had little or no emotional connection, or partners who lived in a participant’s community or were perceived as “higher risk.” Concurrency in Zambia 2010

40. “Multiple Partners”: Perceptions vs. Actual Behavior “INTERVIEWER: Have you ever had a relationship with more than one sexual partner at the same time, like suppose you have a husband and then you also have a boyfriend as well? PARTICIPANT: No. INTERVIEWER: Earlier you had told me that you had a boyfriend, was that before you got married? PARTICIPANT: He [husband] had gone away for 8 months. INTERVIEWER: Were you still married? PARTICIPANT: Yes. “ Concurrency in Zambia 2010

41. Text Data

42. IDIs: Sexual Dynamics Concurrency in Zambia 2010

43. IDI: Major Domains Proportion of IDIs where a theme was coded as present Concurrency in Zambia 2010

44. Sexual Dynamics Concurrency in Zambia 2010

45. Sexual Dynamics “INTERVIEWER: Have you ever had a relationship with more than one sexual partner at the same time? PARTICIPANT: Yes. INTERVIEWER: Why? PARTICIPANT: Ok, there are a lot of contributing factors. Lets say in a marriage and then you find that your wife is pushing you away. What do I mean - Firstly you find that your wife does not want to have sex with you, torturing you mentally, so this will drive you out of your home. You end up having sex with someone outside. The other thing is whenever you go home your wife is always nagging you, so you start shunning away from home and usually it'll drive you to clubs and in those clubs finally you will get somebody to talk to, whether it is in your 100% sober state or partially drunk state somebody will get to you eventually.” Concurrency in Zambia 2010

46. Sexual Dynamics “INTERVIEWER: What about being faithful to [your husband] mean? PARTICIPANT : I can be faithful if he does everything for me, even when I tell him I do not have lotion, he provides it for me. But if he does not, then another guy comes along… INTERVIEWER: How important is it for you to faithful to your husband? PARTICIPANT : The most important thing is to have a respectable name, that I am married.” “INTERVIEWER: How does faithfulness apply to your relationship? PARTICIPANT : Well he is faithful and so am I, he supports me when I don't have money, he gives me, and he is the one who pays school fees for my children. So yeah… he is faithful, though he has a wife, I don't expect him to marry but at least he can support me. “ Concurrency in Zambia 2010

47. Sexual Dynamics “I consider women as a gift, which was given to us. It is like something that you can own at any time you feel like. So it [having multiple partners] was just a question of wanting to taste this one and that one.” “INTERVIEWER: Tell me why you had different sexual partners? PARTICIPANT: Now it's due to current occupation…I 'd leave my wife go very far maybe to ---- and you are [there] 2to 3 weeks and you feel like having sex what do you do, you get one .. I'll be told fat women are sweet so I'd go for fat ones … then another tells me that slim ones are warm then I go for slim ones and that short ones are tight so these are things that were causing me to have a long chain of women.” Concurrency in Zambia 2010

48. Sexual Dynamics “INTERVIEWER: Does your fiancé know any of these two girls? PARTICIPANT: Yes she knows about --. They were at the same school. In fact my fiancé made me fall in love with -- to protect me from other girls. It was a strategic arrangement among themselves.” “PARTICIPANT: The truck driver who l came with used to take care of me in those days. So as the time went by he stopped coming. So like l said, l came to know a man from --- who started helping me. .he came here and as time went by the wife came here and that's how it ended. So now l have this one from ---. But, there times when a friend has two who brings one to you. INTERVIEWER: Bringing you what? PARTICIPANT: May be she has two then she gives you one….a man “ Concurrency in Zambia 2010

49. Sexual Dynamics “Those years before 2006, I was having stable partners but the past year, I was just having sex with different men in exchange for money. I was not even asking them their names or where they came from. What I was only interested in was to have sex in exchange for money, but throughout last year, I was having sex nearly every day with a lot of different men. I cannot remember. “ “INTERVIEWER: On any of these days, did you give GG money, food or a place to stay in exchange for sex? PARTICIPANT : On this one my brother as a man, you always feel a need to give something to someone you have sex with. It's like saying thank you.“ Concurrency in Zambia 2010

50. Sexual Dynamics: Mobility • Fifty-one percent of males and 26% of female who reported “overlapping concurrency” reported one or mor e partners whose primary residence was different that the participant. • Eighteen percent of women and 12% of men who reported monogamous relationships reported that their partner had a different primary residence. Concurrency in Zambia 2010