Multiple Concurrent Partnerships among Men and Women aged in Botswana

Transcription

1 Multiple Concurrent Partnerships among Men and Women aged in Botswana Baseline Study, December 2007

2 Multiple Concurrent Partnerships among Men and Women aged in Botswana Baseline Study, December 2007 Diana Gourvenec, Noah Taruberekera, Obakeng Mochaka, Toby Kasper Contact: Research Department, PSI-Botswana Private Bag 00465, Gaborone, Botswana Tel , Fax ,

3 Table of Contents Summary... 1 Multiple Concurrent Partnerships (MCP)... 2 Research Questions and Methodology... 4 Sample Characteristics... 7 The Extent of MCP in Botswana... 8 Number of Sexual Partners Length and Type of Partnerships Opportunity, Ability and Motivation Determinants of MCP Programmatic Recommendations Annex 1: Monitoring Table, MCP Behavioural Indicators Annex 2: Monitoring Table, Behavioural Determinants Annex 3: Segmentation Tables Annex 4: PSI Performance Framework for Social Marketing Annex 5: Reliability Analysis... 38

4 Summary Acknowledgements This study was funded by the Government of the Netherlands and the President s Emergency Plan for AIDS Relief (PEPFAR). PSI-Botswana s HIV prevention programs are also supported financially by the Africa Comprehensive HIV/AIDS Partnership (ACHAP) and the National AIDS Coordinating Agency (NACA). Background and research objectives The objectives of this study were: (1) to compare different ways of asking about multiple concurrent partnerships (MCP); (2) to identify characteristics of MCP; and (3) to identify behavioural drivers of or barriers to MCP at the individual level. Description of intervention PSI-Botswana s work on MCP began in 2008 with a mass media campaign (via radio, outdoor and print channels) aimed at challenging social norms or received wisdoms that are used to normalise and legitimise MCP. MCP education and messages were subsequently integrated into inter-personal and community-level projects implemented by PSI in partnership with national community- and faith-based organizations and District Multi-Sectoral AIDS Committees (DMSACs). From late 2008, PSI s MCP work will be conducted as part of a multistakeholder national campaign on MCP, led by NACA. Methodology Using the approach of Project TRaC, PSI conducted a national tracking survey of youth and adults aged Cluster sampling methodology was used to select a random sample of households, stratified by district proportionately to population size. 1,787 youth and adults aged were interviewed during December For the purpose of this MCP report, respondents who had never had sex were excluded from the analysis. Main findings Approximately ⅓ to ¼ of Batswana report being engaged in MCP. Asking about concurrency in different ways yields different estimates of the prevalence of MCP. Men are more likely than women to engage in MCP by most estimates. Knowledge that concurrent or overlapping partnerships are more risky is very low (17%). Drivers of MCP are different for men and women and include beliefs, attitudes, self efficacy and alcohol use. Programmatic recommendations MCP interventions should focus initially on creating awareness about concurrency and HIV risk and challenging perceptions of the benefits and costs of MCP. For men this means sexual benefits whereas for women it relates to the other benefits of multiple partnerships that make it difficult to resist the temptation to have different partners. (1)

5 Multiple Concurrent Partnerships (MCP) Southern Africa is the region in the world worst-affected by HIV/AIDS: all the highest HIV prevalence countries are in this region. However, comparison of HIV prevalence with the traditional sexual behaviour indicators, such as age of sexual debut, lifetime number of sexual partners and rates of condom use do not explain the global distribution of HIV infections; the focus has shifted in recent years to the pattern of sexual partnerships, rather than the overall number of sexual partners as the driver of HIV transmission. Looking to the pattern of sexual relationships as a driver of sexually transmitted infections is not new, but it is only in recent years that it has gained widespread credibility and acceptance as an explanation of high HIV rates in Sub-Saharan Africa. The Expert Think Tank Meeting on HIV Prevention in High Prevalence Countries of the Southern African Development Community (SADC) in May 2006 pointed to high of multiple and concurrent sexual partnerships by men and women, with insufficient consistent, correct condom use, and combined with low levels of male circumcision, as the key drivers of the HIV epidemic in the region. MCP describes sexual relationships with more than one person at the same time or over the same period of time. As depicted below, MCP contrasts with the pattern of sexual partnerships in which one sexual relationship ends before another begins and individuals are in only one sexual relationship at any one time; this is commonly described as serial monogamy. There are two key reasons why HIV has spread more rapidly and more widely in societies where MCP is common than those where serial monogamy is more typical: the network effect and viremia, or the acute infection phase of HIV. The sexual network within a society is the way in which individuals are connected to each other over a given period of time through sexual partnerships. Each individual is linked to his or her own sexual partners, to their partners sexual partners, to those people s sexual partners, and so on. Therefore, the more men and women in a society have more than one partner, the more people in the network become linked to each other. Even those who have only one sexual partner themselves are drawn into a much wider network if their partner has other partners. Conversely, the more men and women in a society have only one partner at a time, the fewer people in the network are linked, and if both partners in a relationship are faithful (have no other sexual partners during that relationship) then the couple is isolated from the rest of the network. (It is important to draw a distinction between traditional polygamy, practiced within strict cultural parameters that actually serve to limit sexual networks to a man and his wives, and the multiple concurrent partnerships that are not culturally sanctioned and that result in the dense sexual networks that characterise today s society.) (2)

6 Simplified depictions of sexual networks are shown below: Dense sexual network: many women and men have more than one partner De-linked sexual network: no women and men have more than one partner In a country like Botswana, where adult HIV prevalence in 2004 was estimated at 25.2%, HIV is highly likely to be present in any sexual network that includes more than one or two couples. With higher numbers of men and women linked through sexual partnerships, HIV will be present at more points in the linked network. While self-reported rates of condom use in Botswana are high, qualitative studies paint a different picture, in which condoms are only used in the first weeks or months of a new partnership, and then not always correctly or consistently. The infectiousness of HIV changes over time, being highest during the early weeks after infection when there are high levels of HIV in the blood before antibodies are developed. This is known as the acute infection phase of HIV and infectiousness peaks at around 3 weeks after a person becomes infected. During the acute infection phase a person will not know that they have been infected, because it is too early for the virus to be detected by a normal HIV test, which measures antibodies. After a few weeks, antibodies reduce viral load and the infectiousness of HIV drops off sharply and dramatically, remaining low throughout the asymptomatic or latent infection phase (a rise does occur later in the course of HIV infection, but this typically coexists with comorbid conditions that reduce the frequency of sexual activity). 1 It is the combination of acute infection and linked sexual networks where HIV is already present that makes MCP a risky practice. HIV is able to spread because people who are newly infected then have sex with another person during the acute infection phase. In contrast, in a network where each individual has only one sexual partner at a time, HIV is unable to spread because there are no enabling links. Although there is partner exchange within a network characterised by serial monogamy, people who become infected only begin new sexual partnerships after the acute infection period is over and are thus less likely to transmit HIV to their next partners. 1 This is the standard account of the course of acute HIV infection. However, some preliminary and as-yetunpublished findings from the Botswana Harvard Partnership suggest that in some people infected with HIV-1 subtype C (the dominant subtype in Botswana), the period of peak viremia may extend for several months or more after infection. (3)

7 Research Questions and Methodology Purpose and research questions The purpose of this MCP study was to generate evidence to inform MCP programming in Botswana. The study was designed to provide actionable evidence that agencies undertaking MCP interventions in Botswana will use to improve and develop programs. Based on the study, communications strategies will be deployed to motivate the target group to desist from MCP. The study also serves as a baseline for MCP interventions. This study answered questions relating to MCP study design, identification of determinants of MCP and partner reduction and measurement of key program indicators. Does asking about MCP in different ways produce different results? What characterises MCP in terms of length and type of partnership? What are the baseline levels in behavioural indicators and opportunity, ability and motivation constructs? Among sexually experienced youth and adults aged 15-34, which opportunity, ability and motivation constructs and population characteristics are correlated with MCP? Are some population segments more likely than others to engage in MCP? Project TRaC The study used the approach of Project TRaC (Tracking Results Continuously), PSI s quantitative research, monitoring and evaluation tool for collecting cross sectional behavioural data. TRaC uses a similar approach to traditional KAP surveys, but is unique in two ways: firstly, it is heavily rooted in the behaviour change framework which is the core of PSI s social marketing and health communications programming; and secondly it is designed with the end use of research findings in mind. Towards that end, it builds upon the backwards research process where decision-makers first identify the potential decisions that will be based on research findings; this produces the list of indicators or areas of enquiry to be included in the survey. TRaC surveys also differ from standard KAP studies in the way they use psychographic scales to capture the multidimensional and complex concepts that form the determinants in PSI s behaviour change framework. The PSI behaviour change framework and Performance Framework for Social Marketing is attached as an appendix. Methodology This TRaC study was conducted in Botswana during December The sample size was 1,787 males and females aged For the purpose of MCP analyses, respondents who had never had sex were excluded from the sample. (4)

8 The total minimum sample size was calculated based on the target percentage decrease in MCP; the sample was then stratified by district and ward based on population data obtained from the second Botswana AIDS Impact Survey (BAIS II), and wards were further divided into enumeration areas (residential blocks) by field supervisors. The first two houses to be sampled in each enumeration area were selected randomly beginning in opposite corners of the enumeration area, and thereafter, every three houses in the block were surveyed, up to a maximum of ten households per enumeration area. Inclusion criteria included age and voluntarily agreeing to participate in the survey. Where the randomly selected premises did not meet the inclusion criteria, the interviewer proceeded to the next house. The questionnaire was administered by a trained interviewer in Setswana and took approximately 45 minutes to complete. The questionnaire included population characteristic, behaviour, opportunity, ability, motivation and media consumption items. A copy of the questionnaire in English and Setswana is available on request from PSI. Statistical analysis was performed with SPSS. Data was initially cleaned to correct out of range, outlying and missing responses. Exploratory factor analysis using varimax rotation was used to identify the number of different dimensions or subscales within each group of items. Uni-dimensional scales containing a minimum of 3 items were then created and the Cronbach s alpha test of internal reliability within each uni-dimensional scale was performed. Scales with an alpha value < 0.65 were not included, alpha >0.65 is considered minimally acceptable, and > 0.70 acceptable. Composite variables were then created for the multi-item scale by computing the mean response across all items and cases. Where multi-item scales could not be created, individual questionnaire items for the behavioural determinant in question were used. Bivariate correlations between the outcome of interest and potential determinants were examined, logistic regression models were built, ANOVA MCA analysis was used to calculate adjusted proportions, and indicators were analysed for significance using the chi-squared test of null hypothesis of two independent variables. Limitations For unforeseen logistical reasons, it was not possible to collect data in Ghanzi and Selibe- Phikwe districts. Responses to questions about sexual behaviour and determinants of behaviour are subject to social desirability bias (in which respondents provide answers that reflect their perceptions of the correct answer rather than their actual behaviour). Segmentation analyses were performed on a national sample and cannot identify regional differences in the determinants of MCP. The sample included only those aged 15-34; therefore conclusions regarding behavioural indicators or determinants of behaviour cannot be assumed to apply to adults over the age of 35. Segmentation analyses assess determinants of behaviour at the individual level and results should be interpreted in the (5)

9 context of an understanding of the societal factors that drive risk behaviour or inhibit behaviour change. Presentation of results Study results are presented in this report in PSI s set of standardized tables for segmentation, monitoring, and evaluation of populations. Segmentation tables answer questions about which opportunity, ability and motivation constructs and demographic characteristics are correlated with engagement in MCP and about the profile of target group segments who are not engaged in MCP. This information is then used alongside analysis of societal or infrastructural drivers of MCP and barriers to behaviour change, as well as qualitative studies, to develop intervention messages which will target the appropriate drivers of risk behaviour or barriers to change. Monitoring tables present levels and trends in key MCP indicators. This study provides baseline figures for key MCP indicators. Evaluation will be undertaken at the mid-term and end of the upcoming national MCP campaign. At the second round of survey, the differences in desired behaviour between first and second round are assessed and differences are correlated with exposure to interventions. A high level of correlation in a positive direction would indicate high program effectiveness. (6)

10 Sample Characteristics Table 1: Sample characteristics POPULATION CHARACTERISTICS Total sample size (ever had sex) 1,073 Gender Male 50% Female 50% Age of respondents Mean Median 25 Urban / peri-urban 31% Residence Urban village 24% Rural area 45% None / informal 4% Primary 8% Highest educational level attained Junior secondary 35% Senior secondary 38% Above senior secondary 15% Unemployed 46% Student 15% Employment status Self employed 10% Employed - professional 7% Employed other 22% Sexually transmitted infections: Male 6% had a genital sore or ulcer in the last 12 months Female 17% The gender and residence characteristics of the sample population of this study were broadly in line with those of the 2004 BAIS II study. BAIS II revealed a gender imbalance in the population with 53% females and 47% males. BAIS II shows that 46% of the population of Botswana lives in rural areas, with 54% distributed between urban areas, peri-urban areas and urban villages. However, the education and employment profile of respondents in this study differed from BAIS II. 12% of the BAIS II sample had never attended school and 35% had only attended school up to primary level, suggesting that less educated people were under-represented in this study sample. Conversely, BAIS found an unemployment rate of 25%, suggesting that unemployed people are over-represented in this study sample. BAIS II found that 45% of the population were in active employment, so the 39% of this sample who were employed does not differ greatly from BAIS II. (7)

11 The Extent of MCP in Botswana Asking about sexual behaviour is always tricky and doing so in a country such as Botswana where knowledge of HIV/AIDS is high and where consensus is culturally valued poses special problems. These factors may combine into the phenomenon of social desirability bias, in which respondents provide answers that reflect their perceptions of the correct answers rather than their actual behaviour. Additionally, there are no internationally agreed-upon indicators for the measurement of MCP. For both of these reasons the 2007 TRaC study asked about MCP in three ways: (1) How many different partners did you have sex with during the last 12, 6 and 1 months; (2) How many different people did you have sex with during each of the last 6 months; and (3) When did you first have sex with your last (up to) 3 sexual partners, and are you still having sex with that partner. This approach facilitates understanding of the phenomenon by enabling comparisons of how different sets of respondents reacted differently to the ways of asking about concurrency. It also ensures that baseline data is available for multiple indicators, building in flexibility as national and international discussions about MCP advance in the coming years. Below, the results for the different ways of asking about MCP are presented and compared. In summary, when a composite indicator is developed from these questions, 32% of men and 26% of women can be considered to have engaged in concurrent relationships. From the first set of questions, mean numbers of partners of different types and combinations of types over the three time periods were calculated. For this question, partner type was split into the following groupings: marital/cohabiting, other regular, and casual/commercial. When MCP was asked about in this way, men reported more partners than women. When other population characteristics were adjusted for, there were no significant differences in total numbers of partners during the last 12 and 6 months by demographic factors such as age, area of residence, employment status and level of education. Table 2: Number of partners by gender INDICATORS All Gender Male Female Sig. Had more than 1 partner in last 12 months 25% 33% 17% *** Had more than 1 partner in last 6 months 16% 22% 9% *** Had any casual partner in last 12 months 16% 23% 10% *** Significant when adjusted for residence, age, educational level, employment, marital status and parenthood (8)

12 Significance *<.05; **<.01; ***<.001; NS: not significant As expected, those who were married or cohabiting at the time of the survey were less likely to have had zero or one partner during the last 12 months, because there were no married or cohabiting respondents who reported zero partners in the last year. However, when non-married / non-cohabiting respondents with no partner in the last 12 months were excluded from the analysis, married or cohabiting respondents were not more likely to have had more than one partner in the last 12 months. Table 3: Number of partners by marital status INDICATORS All Married or cohabiting Marital status Not married or cohabiting Had more than 1 partner in last 12 months 25% 32% 23% ** Had more than 1 partner in last 12 months, of those with any partner Sig. 35% 32% 36% NS Significant when adjusted for gender, age, residence, educational level, employment and parenthood Significance *<.05; **<.01; ***<.001; NS: not significant From the second set of questions, a single indicator of MCP risk behaviour was calculated, of whether the respondent reported more than one sexual partner during any of the preceding 6 months. When asked about concurrency in this way, and other population characteristics were adjusted for, men once again reported more partners than women, but other demographic factors were not significant determinants of concurrency. This set of questions was also used to calculate the partner numbers during the last month, and the results appear consistent with the data presented above for numbers of partners during the last 12 and 6 months. Men again reported more partners when the question was asked in this way. Table 4: Concurrent partnerships in same month by gender INDICATORS Had more than one partner in same month during any of the last 6 months All Gender Male Female Sig. 19% 25% 12% *** Had more than one partner in last month 11% 14% 6% *** Significant when adjusted for residence, age, educational level, employment, marital status and parenthood Significance *<.05; **<.01; ***<.001; NS: not significant From the final set of concurrency questions, two indicators of MCP were developed, still having sex with more than one partner at the time of the survey and starting a new partnership at any time during a partnership that was ongoing at the time of the survey. (9)

13 When asked about their partners in this way, men and women reported identical levels of concurrency. There was also no significant difference between youth and adults, but more rural residents reported starting an additional partnership during the course of a partnership that was ongoing at the time of the survey. It is striking that more men and women reported still having sex with more than 1 of their last 3 partners than reported having more than 1 sexual partner in the last month. More women also reported still having sex with more than 1 of their last 3 partners than reported more than 1 sexual partner in the last 6 or 12 months or than reported more than one partner in the same month during any of the last 6 months. One possible explanation could be that although respondents may not have sex with a particular partner during the last month, they had probably had sex with them quite recently and intended to have sex with them again in the future. The most notable finding is that asking about concurrency in this way produced identical estimates of MCP for men and women, whereas the other ways of asking showed significantly more men engaged in MCP than women. There are different possible explanations that should be explored via qualitative research. Building on the point above, it could be that women considered themselves to be still having sex with a partner even if they had not had sex with them in some time, because they considered it likely they would have sex with them again in the future, and the transactional nature of many sexual relationships may play a role in this calculation. It could also be that this less direct way of asking about numbers of sexual partners was less intrusive for women and elicited more truthful responses. Table 5: Concurrent partnerships at time of survey by gender and residence INDICATORS Still having sex with more than 1 of last 1-3 sexual partners at time of survey Started an additional partnership during the course of a current partnership All Gender Residence Male Female Sig. Rural Other Sig. 20% 21% 20% NS 22% 19% NS 30% 30% 30% NS 36% 26% *** Significant when adjusted for residence, age, educational level, employment, marital status and parenthood Significant when adjusted for gender, age, educational level, employment, marital status and parenthood Significance *<.05; **<.01; ***<.001; NS: not significant In summary, the different ways of asking about concurrent partnerships produce results that are broadly similar, with the important caveat that the third approach elicited a different pattern of response from women and men than the first two. Since it is not possible to determine which of the three approaches most accurately reflects reality, for the purposes of monitoring changes around MCP over time a composite indicator was developed that combines the different approaches. This ensures that those who report (10)

14 concurrent relationships when asked in one way but not when asked in a different way are captured. The composite indicator includes those reporting that they were still having sex with more than one partner at the time of the survey or had more than one partner in the same month during any of the last 6 months. Table 6: Composite MCP indicator INDICATORS All Males Females Sig. Still having sex with more than 1 of last 1-3 sexual partners at time of survey Had more than 1 partner in same month during any of the last 6 months 20% 21% 20% NS 19% 25% 13% *** Engaged in MCP by either of above definitions 29% 32% 26% NS Significant when adjusted for residence, age, educational level, employment, marital status and parenthood Significance *<.05; **<.01; ***<.001; NS: not significant The study also asked scaled response questions (strongly disagree, disagree somewhat, neither agree nor disagree, agree somewhat, strongly agree) about whether respondents friends and partner were engaged in MCP: My friends have more than one partner at the same time, and I think my partner has had another sexual partner since we have been together. The proportion of respondents who said that their friends are engaged in MCP or who thought that their partner had engaged in MCP during the course of their relationship was higher than the proportion of respondents who reported that they themselves were engaged in MCP. As shown in Table 7 below, 49% of men agreed or strongly agreed that their partner had had another partner since they had been together, compared to 30% of women who reported that they had had another partner during the course of a partnership that was ongoing at the time of the survey. Similarly, 54% of women agreed or strongly agreed that their partner had had another partner since they had been together, whereas only 30% of men reported that they had had another partner during the course of a partnership that was ongoing at the time of the survey. 56% of men and 51% of women agreed or strongly agreed that their friends have more than one partner at the same time, compared to 32% of men and 26% of women who reported that they themselves are engaged in MCP by the composite indicator described above. Table 7: Own, friends and partners engagement in MCP INDICATORS All Males Females Agree or strongly agree that I think my partner has had another sexual 51% 49% 54% (11)

15 partner since we have been together Started an additional partnership during the course of a current partnership Agree or strongly agree that My friends have more than one partner at the same time Still having sex with more than 1 of last 1-3 sexual partners at time of survey or had more than 1 partner in same month during any of the last 6 months 30% 30% 30% 53% 56% 51% 29% 32% 26% A comparison of recent quantitative research on MCP in Botswana reveals that the results of this study are broadly in line with other estimates of MCP. For example, the 2003 Makgabaneng Radio Serial Drama Listenership Survey of men and women aged in 7 of the 11 most populous districts of Botswana 2 found that 30% of men and 14% of women aged reported more than one partner in the last 12 months. A 2004 Physicians for Human Rights survey of males and females aged in the five districts with highest HIV prevalence in Botswana 3 found higher rates of multiple partnering, with 45% of men and 28% of women reporting more than one partner in the last 12 months. The 2007 national CIET Trust survey of HIV and AIDS related knowledge, attitudes & practice among males and females aged found that overall 25% of men and women aged reported more than one partner in the last 12 months. In the 2007 Kalichman survey of HIV positive males and females recruited through ARV clinics and support groups in Gaborone 5, 20% of respondents reported more than one partner in the last three months. 2 Makgabaneng Radio Serial Drama Listenership Survey Report, Botswana May Katina A. Pappas-DeLuca1, PhD, Todd Koppenhaver2, MHS, and the Makgabaneng Listenership Survey Group, Epidemic of Inequality Women s Rights and HIV/AIDS in Botswana & Swaziland: An Evidence-Based Report on the Effects of Gender Inequity, Stigma and Discrimination. Physicians for Human Rights Survey of HIV and AIDS related knowledge, attitudes & practice, CIET Trust Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS in Botswana, Kalichman et al, Sexually Transmitted Infection 2007;83; (12)

16 Number of Sexual Partners Using the composite indicator of concurrent relationships described above, 32% of men and 26% of women were engaged in MCP in December Engaged in MCP as used in the charts below means by this definition. Figure 1 below shows the proportions of respondents reporting 0, 1, 2, 3-4 and 5 or more sexual partners during the last 12 months. The mean number of partners reported during the last 12 months was 1.69 for men and 0.93 for women. More women reported having no sexual partners and more men reported three or more. When the 20% of men and 34% of women who had ever had sex but reported no sexual partners in the last 12 months are removed, 41% of men and 26% of women had more than one partner in the last year and the mean number of partners rises to 2.1 and 1.41 respectively. Figure 1: Total number of sexual partners in last 12 months who have ever had sex All Men Women who had any partner in last 12 months All Men Women (13)

17 Length and Type of Partnerships In order to better understand the multiple concurrent partnerships that potential target groups are engaged in, it is useful to analyse the duration of partnerships and the prevalence of partnerships of different types. In general sexual relationships are strikingly short. Respondents were asked when they first had sex with their last 1-3 sexual partners. Of all the ongoing partnerships reported on, 23% had begun less than four months ago and 69% of these less than one month ago, as shown in Figure 2 below. There was little difference between the length of time since first sex with all partners and in partnerships that were ongoing at the time of the survey. This pattern of reporting hints at frequent partner exchange and under-reporting of total partner numbers per year Figure 2: Months since first sex in last 1-3 partnerships (14)

18 More of the partnerships reported by men had begun during the last year, and more of the partnerships reported by women had begun more than two years ago, as shown in Figure 3 below. Figure 3: Months since first sex in respondents last 1-3 partnerships, by gender Comparing the partnerships of those engaged in MCP with those of people not engaged in MCP (by the composite MCP indicator presented in Table 6), more of the partnerships of people who were engaged in MCP had begun within the last year and fewer partnerships of people engaged in MCP had begun more than two years ago, as shown in Figure 4 below. Figure 4: Months since first sex in respondents last 1-3 partnerships, by MCP Figure 5 below shows the distribution of current sexual partnerships (partners who respondents reported they were still having sex with ) by duration and type. It is noticeable that more of the partnerships reported by those engaged in MCP had begun in the last year (15)

19 and / or were described as casual partnerships, whereas more of the partnerships of those not engaged in MCP had begun more than two years ago and / or were described as marital or cohabiting partnerships. For example, casual partnerships accounted for 23% of the current partnerships of those engaged in MCP but only 5% of the current partnerships of those not engaged in MCP. Conversely, marital or cohabiting partnerships represented 38% of the current or most recent partnerships of those not engaged in MCP but only 19% of the last 2-3 partnerships of those engaged in MCP. Partnerships begun in the last year were 47% of the partnerships reported by those engaged in MCP, compared to 35% of the most recent partnerships of those not engaged in MCP. Figure 5: Months since first sex in current partnerships, by partner type and MCP PSI s qualitative research (focus groups and in-depth interviews) shows that the term regular is used to describe partners at a fairly early stage of a relationship: after a few weeks or even a few sexual acts. There is also considerable overlap between regular and casual partnerships, with no-strings partnerships being described by some as casual even if they are regular and ongoing. As is clear from the graphs above, the term casual cannot be understood to mean one-night stands: 8% of partnerships that began four or more months ago and were ongoing at the time of the survey were described as casual ; among those (16)

20 engaged in MCP, 13% of current partnerships that began four or more months previously were described as casual. When considering partnerships described above as marital or cohabiting, it should be borne in mind that co-habitation has a very different status to marriage in Botswana. Whereas many couples may co-habit quickly, marriage rates are very low. Co-habitation also does not carry the expectation of long term commitment and sexual fidelity that marriage does. (17)

21 Opportunity, Ability and Motivation Determinants of MCP Methodology The monitoring and segmentation tables at Annex 2 and Annex 3 present baseline data for opportunity, ability and motivation determinants of MCP among a representative sample of sexually experienced youth and adults aged in Botswana in December The monitoring table presents opportunity, ability and motivation indicators for the whole sample, while segmentation tables show which factors correlate positively with different indicators of MCP risk behaviours. Opportunity, ability and motivation determinants are drawn from the PSI behaviour change framework, shown at Annex 4. Opportunity refers to institutional or structural factors that influence an individual s chance to perform a promoted behaviour. Opportunity can be changed by the intervention but is outside the control of the individual. Ability is an individual s skills or proficiencies needed to perform a promoted behaviour. Motivation is a goal-directed desire. Factors that drive motivation are within the individual and cannot be seen. More detailed definitions of behavioural determinants are included in Annex 4. The TRaC questionnaire groups opportunity, ability and motivation items into the factors presented at Annex 4. Scaled responses are given whereby 1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree and 5=strongly agree. Where the statement is a negative one in relation to the desired behaviour (e.g., It is acceptable in my community that men will always have multiple sexual partners ) responses are reverse coded so that 5 becomes strongly disagree with the negative statement; thus 1 is the least desirable response and 5 the most desirable for these questions as with all others. For scaled responses mean scores close to 4, suggesting respondents typically agree with positive statements relating to the behavioural determinant in question, can be considered high. Monitoring Analysis (see Annex 2) Generally, opportunity, ability and motivation responses were very positive, with mean scores close to 4 on the majority of indicators. People generally experienced positive social norms about number of sexual partners; expressed high self-efficacy regarding alcohol and sex and transactional sex; received positive social support for reducing partners; had high risk perception around MCP and condom use; and expressed positive beliefs, attitudes, outcome expectations and subjective norms relating to multiple partners. (18)

22 A critical finding of this study relates to very low levels of knowledge and risk perception in relation to concurrent partnering. To test knowledge about concurrency and HIV risk, respondents were presented with two scenarios, one of three overlapping partnerships and one of three partnerships with breaks in between and asked which scenario represented higher HIV risk. Just 17% of men and women aged who had ever had sex correctly identified the overlapping partnership scenario as more risky; 74% thought the risks were the same and 9% said that the serial monogamy scenario was more risky. This shows that although Batswana are generally highly HIV-literate, there is a need for better information about how and why concurrent or overlapping sexual partnerships mean higher risk of transmitting or contracting HIV. Perceived general susceptibility to HIV infection (people s personal perception of how likely they were to get HIV) was low, which must be of concern in a generalized epidemic with 25.2% adult prevalence according to BAIS II. The extent to which people perceived that the locus of control to prevent HIV lies within them rather than beyond their control was also low. However, with 40% of people living with HIV and AIDS ever having tested for HIV (BAIS II), a significant minority of study respondents would have known they were positive and thus may have been more likely to report that they could not control whether they would get HIV in the future. Social norms about transactional sex are lower than many other behavioural determinants. These measured how normal it is to have partners who give presents or look after different needs. It is interesting that males and females gave very similar responses, although it is possible that men may have been referring to female friends who receive gifts from partners and/or have interpreted various needs to mean sexual as well as material needs. Self-efficacy to resist the temptation to have other partners was also low relative to other variables, with 21% of respondents disagreeing or strongly disagreeing that they were not tempted to have sex with anyone other than their current partner at the time. Possible links between these determinants of MCP are discussed in the segmentation analysis below. Although social norms relating to disapproval of having multiple partners were very positive, social norms perceived to support MCP were closer to neutral, indicating conflicting norms about the normality or acceptability of MCP. Men s and women s perception of their ability to control when they have sex differed significantly, with women more likely agree that they have less control over when to have sex. (19)

23 Segmentation Analysis (see Annex 3) Four different MCP risk behaviours were analysed: (1) still having sex with more than one partner at the time of the survey; (2) having more than one different partner in the same month during any of the last six months; (3) having more than one partner in the last 12 months; and (4) having any casual partner in last 12 months. Additionally, the composite indicator still having sex with more than one partner at the time of the survey and having more than one different partner in the same month during any of the last six months was analysed. By segmenting by different risk behaviours, it was possible to capture all the different behavioural drivers and barriers that emerge as significant when MCP is asked about in different ways. The table below summarizes the opportunity, ability and motivation factors that correlate positively with at least one indicator of MCP risk behaviour: Table 8: Summary of determinants of MCP Behavioural determinants that make people significantly more likely to engage in MCP Do not know overlapping sexual relationships are more risky Overall Males Experience less encouragement from friends to have 1 sexual partner Are less affected by elder / community disapproval of multiple partners Believe less in their ability to resist temptation to have other partners Drink alcohol to excess or to gain confidence Believe more strongly in the benefits of having multiple partners (choosing among them, ease of moving on, peer prestige, sexual satisfaction, not sleeping alone) Believe that having multiple partners is no problem if condoms are used Think sex doesn t require or signify love or emotional commitment Feel more strongly that they do not control when they have sex Females Demographic correlates of MCP Men were significantly more likely than women to report three of the four risk behaviours: having more than one different partner in the same month during any of the last six months, having more than one partner in the last 12 months and having any casual partners in the last 12 months. Other demographic drivers of MCP emerged less consistently. For example, those reporting any casual partner in the last 12 months were significantly more likely to be aged than Those who reported more than one partner in the last 12 months were significantly more likely to be married or cohabiting at the time of the survey, but this is to be expected as the behavers segment includes those with no sexual (20)

24 partner in the last year and married or cohabiting men and women would have a minimum of one partner. Other population characteristics such as level of education, parenthood, socio-economic status and employment status did not correlate either positively or negatively with any of the dependent variables analysed. Determinants of MCP among men (Tables S1, S3, S4, S6, S8, S10, S11) For men, the behavioural determinants that most consistently correlated with MCP behaviours were beliefs in the benefits of having multiple partners and the belief associated with the risk of MCP that as long as condoms are used having multiple partners should be no problem. Other determinants that correlated with fewer MCP behaviours were social support from friends to have only one partner and attitudes about sex not requiring or signifying emotional commitment. Self efficacy to avoid risky sexual behaviour when under the influence of alcohol correlated with casual partners only. Knowledge about concurrency and HIV risk correlated with partner reduction when men and women were considered together. Thus the segmentation analyses tell us that men are significantly more likely to have multiple concurrent partnerships if they: Believe more strongly in the benefits of having multiple partners; Believe that having multiple partners is no problem as long as condoms are used; Experience less social support from friends for having only one partner; Believe more strongly that sex does not require or signify emotional commitment; Do not know about the specific HIV risks inherent in concurrency; and Have lower self efficacy to avoid casual partnerships when drinking. The specific beliefs about the benefits of having multiple partners that respondents were asked about were: being able to chose the best partner among them; ease of moving on to the next partner if there is a fight with one of the partners; never having to sleep alone or sleep with a broken heart; getting more sexual satisfaction; and enjoying prestige among peers. When the multi-item scale was replaced in the final logistic regression model with all the individual items that made up the scale, none was significant on its own. This suggests that it is not one particular benefit of multiple partners that drives concurrent and casual partnerships, but rather the aggregate of all the different benefits. It is tempting when seeking to address the complex issue of MCP to say that promoting condom use, particularly outside of primary partnerships, is the answer. There are two main problems with this approach. Firstly condom promotion targeting those engaged in MCP would send conflicting messages and undermine efforts to reduce MCP. These data show that men who believe that having multiple partners is no problem when condoms are used are significantly more likely to engage in MCP, strengthening the view that sending (21)

25 men the message that condoms are an alternative to partner reduction is likely to undermine efforts to reduce MCP. Secondly, although reported condom use in Botswana is very high with all types of partner, qualitative research paints a very different picture, suggesting that condoms are only used for the first few months, weeks or even sexual acts with a new partner. Addressing condom use with trusted partners has proven challenging in a number of African countries and there is little reason to think that it would be dramatically more successful in Botswana. Taken together, these two factors mean that relying on condom promotion alone could actually increase HIV transmission. The correlation between peer social support for having only one sexual partner and engagement in MCP could be linked to concepts of masculinity and the way men rate themselves against each other in terms of how many partners they have: men whose peers encourage each other to stick to one partner feel less pressure to engage in MCP to impress other men. The attitudes to sex and emotional commitment that respondents were asked about were: Sex for me has no emotional value ; If I have sex with someone it does not mean that I love that person ; I can have sex without any emotional commitments ; and Sex has no value so I can have it with anybody. The significant correlation between these attitudes and sleeping with more than one partner at the time of the survey suggests that those with more than one partner at a time de-link sex and love or emotional commitment in their minds to a greater extent than those who only have one partner at a time. The variable relating to self-efficacy to avoid risky sexual encounters after consuming alcohol was composed of three questionnaire items: There have been times that I was too drunk to remember who my partner was ; Sometimes I do not remember who I had sex with in the morning ; and After a few drinks, it is easy for me to pick up new partners. These pertain more to casual sex scenarios and it is thus not surprising that lower selfefficacy regarding alcohol and sex correlates with casual partnerships but not with other MCP behavioural indicators. Determinants of MCP among women (Tables S2, S3, S5, S7, S9, S10) Among women, the behavioural determinants that most consistently correlated with MCP risk behaviours were social norms about number of sexual partners, self-efficacy to resist temptation to have other partners and self-efficacy to avoid risky sexual behaviour when under the influence of alcohol. Lack of ability to decide when to have sex correlated with having more than one partner during the last 12 months. As noted above, knowledge about concurrency and HIV risk correlated with risk behaviour but not when women only were considered. (22)

26 From the segmentation analyses presented at Annex 3, we can see that women are significantly more likely to have multiple concurrent partnerships if they: Perceive less strongly community disapproval of having multiple partners; Have lower self-efficacy to resist the temptation to have other partners; Have lower self-efficacy to avoid risky sexual behaviour when drinking; Express less power to control when they have sex; and Do not know about the specific HIV risks inherent in concurrency. Setswana culture strongly censures promiscuity and respondents were asked how strongly they agreed that having multiple partners is disapproved of. This included elders in the community strongly disapproving of having many partners, elders in the community disapproving of older men having sex with younger women, people in the community disapproving if they know that you have sidekicks, and losing one s social status if people in the community know that you have sex with other partners. The fact that these social norms correlate positively with practice of a number of desired partner reduction behaviours by women indicates that, for women, traditional cultural values are a positive force when it comes to reducing MCP. In key informant interviews conducted by PSI during preparation for the planning of the forthcoming national MCP campaign, material gain was frequently cited as a motivation for women to engage in MCP. The significance of self-efficacy to resist the temptation to have other partners may therefore be linked to the benefits in terms of material goods, lifestyle and personal advancement that women derive from having additional partners. Women aged years old are living in a rapidly growing economy where they see modern luxuries in the hands of others and widely advertised in the media. However, wealth inequality is high and women still earn less than men. It is therefore possible that the lower self-efficacy to resist temptation to have other partners among women engaged in MCP may be about resisting the temptation to engage in sexual partnerships either to provide for basic needs or in exchange for consumerist wants. As noted in the monitoring analysis above, women expressed lower ability than men to control when they have sex, and qualitative research confirms that it is normal for men to make decisions regarding sex. The segmentation analysis suggests that women with lower decision making power regarding sex are also more likely to have multiple partners. As noted above, self-efficacy to avoid risky sexual encounters after consuming alcohol comprises the items: There have been times that I was too drunk to remember who my partner was ; Sometimes I do not remember who I had sex with in the morning ; and After a few drinks, it is easy for me to pick up new partners. The fact that lower self-efficacy regarding alcohol and sex correlates so consistently with engagement in MCP by women resonates with a drinking culture in which men will buy women drinks for a night in the (23)