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Partner reduction has been identified as an important approach to reducing the risk of HIV transmission at the individual and population levels. Although young people report having multiple sexual partners, few HIV prevention programs for youth address this important driver of the HIV epidemic. This brings several critical questions to mind:

  •  How can the topic of multiple sexual partners be overlooked when young people admit to engaging in this risky behavior?
  • Why do young people engage in these risky sexual relationships?
  • How can youth program staff discuss this important topic without resources and activities to support their work?

These are some of the core questions that led to the development of Promoting Partner Reduction: Helping Young People Understand and Avoid HIV Risks from Multiple Partnerships (PPR). FHI 360 (on behalf of USAID’s IYWG) and ETR Associates created PPR to address a gap in resources. The late Dr. Doug Kirby was a major contributor to this document.

PPR is an evidence-based, participatory set of activities designed to positively affect young peoples’ knowledge, attitudes, values, and intentions to reduce multiple partnerships. The resource contains seventeen activities designed to address multiple partnerships in young people, with an emphasis on those that are overlapping or concurrent (sometimes referred to as “multiple concurrent partnerships” or MCP). The activities were developed with the input of experts around the world and were field-tested among young people in the United States, Botswana and Kenya, and recently piloted by programs in South Africa and Swaziland. Promoting Partner Reduction will help young people:

  • Learn why HIV spreads at different rates in monogamous, sequential, and concurrent sexual partnerships
  • Analyze the reasons why young people engage in multiple partnerships
  • Develop the intention to reduce their number of sexual partners
  • Practice skills to refuse engaging with concurrent partners
  • Examine the role that gender norms play in encouraging multiple partners

By moving beyond the simple message of “avoid multiple partners to protect oneself from HIV,” PPR provides a forum for young people to discuss complex topics such as transactional sex, partner reduction, intergenerational sex, gender and cultural norms, and behavior change through role plays, icebreakers, storytelling, and other engaging activities. Discussion questions and additional activities give special consideration to gender, sexual orientation, HIV status and participants’ experience with violence. Its participatory approach is designed to motivate young people to change their high-risk behaviors.

Results from a three-month pilot intervention found that youth program staff recognize a need for PPR, feel prepared to implement activities, intend to use it, and have a plan for integrating the activities into existing programs. The following quotes highlight their enthusiasm about the need for this new resource:

“Prior to the training, we did not have a specific tool that focuses on addressing partner reduction. It was not discussed in detail in our program.”
-FLAS

“This tool is so important to give out information to youth…whether in church, door to door, home-based, clinic or youth centre. We need this resource. “
-loveLife“

“Most youth living in urban areas or townships, they engage in MCP because they think it’s cool…even though they know the risks.”
-loveLife

Could your program benefit from this resource? Are there young people in your community engaging in multiple sexual partnerships? Perhaps PPR can help you get the conversation started about this often taboo and complicated topic. Promoting Partner Reduction is available electronically on the IYWG website, http://www.iywg.org. To order additional hard copies or a flash drive with a PDF of the publication, please write to youthwg@fhi360.org or to FHI 360, P.O. Box 13950, Research Triangle Park, NC 27709 USA.

Marta Pirzadeh is a technical officer on FHI 360’s Research Utilization Youth Team.

Multiple and concurrent partnerships, “the big house,” “spare tire,” and sugar daddy—these are just a few of the terms used to refer to multiple sexual partners. Even though there are many ways to refer to such partnerships, the risk is the same: within a large sexual network, HIV is spread more quickly and entire communities are being affected. In South Africa and many other countries with generalized epidemics, the high HIV prevalence rates are caused in part by people having unprotected sex with multiple partners, especially when those sex partners are concurrent. But, what causes young people to engage in such risky behavior when they know the consequences? Doesn’t everyone know that if you have unprotected sex with multiple partners, you are putting yourself and others at increased risk of contracting HIV? It seems simple, but I learned on a recent trip to South Africa, that it’s much more complicated than you would think.

“Most youth living in urban areas or townships, they engage in MCP because they think it’s cool…even though they know the risks.”
-LoveLife

“Many girls are not ashamed of MCP (having multiple partners), but actually happy that they are beating the boys at their own game.”
-FLAS

The list of reasons why young people have multiple sexual partners is long and multifaceted. Although it varies by individual, community and country, common themes appear when young people are asked about this risky behavior:  the influence of their peers and role models, the desire for emotional or sexual satisfaction, to receive gifts, as a reflection of gender norms, the influence of alcohol or drugs, as a “ticket out” of poverty, the impact of transactional sex (having sex in exchange for something you want or need), cultural expectations, love, lust…and on and on.  How can youth programs even begin to combat this extensive list? What tools are available to help young people understand the increased HIV risks associated with having multiple partners?

Partner reduction has been identified as an important approach to decreasing the risk of HIV transmission at the individual and population levels.  Having fewer lifetime partners is strongly associated with a reduced risk of HIV infection. Yet, even though multiple sexual partnerships are a major driver of the HIV epidemic, this topic is often inadequately covered in HIV prevention curricula for young people. During a recent trip to South Africa to provide training to youth program staff, my primary questions were: “Is your program addressing the importance of partner reduction?” and “What resources do you have to educate young people on this topic?”

Youth program staff from LoveLife, South African Council of Churches (SACC), Family Life Association of Swaziland (FLAS) and AMICALL-Swaziland attended a training that I facilitated on a new educational tool developed by FHI 360 and ETR and funded by USAID. Promoting Partner Reduction: Helping young people understand and avoid HIV risks from multiple partnerships (PPR) was designed to supplement existing YSRH/HIV programs, and I had the incredible experience of introducing this set of activitiesto these four programs. All four programs are already doing the hard work; they are providing support, life skills training, YSRH and HIV education to young people in some of the communities at highest risk for HIV infection in two countries with some of the highest rates of HIV in the world.  Yet, they were not discouraged by these overwhelming circumstances; rather, they were eager to learn new skills and excited about sharing the activities with program participants.   During our training and discussions, they admitted the risks associated with having multiple sexual partnerships are often overlooked. As one Fcover of Promoting Partner ReductionLAS staff person stated, “Prior to the training, we did not have a specific tool that focuses on addressing partner reduction. It was not discussed in detail in our program.” There was general consensus that multiple sexual partnerships are common among young people but they don’t have the information or resources to address it, so the topic is provided very limited coverage. We hope that by introducing this set of activities, they will be able to integrate them into their already successful programs. It’s a lofty goal; sexual partnerships are complicated and the reasons that young people are involved in them are often even more complex, but perhaps by providing simple activities and guidelines to a few programs, we can begin to see a change.

My trip to South Africa was a small part of an ongoing assessment of PPR. Over the next three months, all four programs will pilot select activities to gauge youth response, and facilitators will be interviewed about their experience. From their experiences, we hope to begin to understand program gaps and learn how we can expand the reach of partner reduction activities to other programs. 

It’s a big topic that needs to have its own time. It’s a socialization topic, it’s a sexual topic. You cannot talk about MCP without talking about gender, society, etc. As much as it can be integrated within existing program, there needs to be time that is set aside just to deal with MCP.
-FLAS

Promoting Partner Reduction: Helping young people understand and avoid HIV risks from multiple partnerships will be available through www.iywg.org in the late fall of 2012.

John Boke Mwikwabe is a peer educator in Naivasha, Kenya. This is the third blog post written by John. To read more about John, see What It’s Like to Be a Peer Educator, posted on March 18 and One Peer Educator’s Biggest Challenge, posted March 21.

When the campaign against HIV/AIDS started, all we heard was how abstinence would be the solution to not getting the infection. But the long discussed and argued question still remains: is there a single way to avoid being infected by HIV? What is the connection between an individual’s intention to heed good advice and their actual behavior? Do people know the consequences involved in various risky behaviors and end up indulging in them anyway?

Those are some of the questions that came to mind when we tested new activities from FHI on reducing multiple concurrent partnerships. The activities had been divided into seven sessions, all of which were dealing with two types of sexual relationships/partnerships: sequential and overlapping sexual relationships.

After almost two months working with these activities, here are some of the issues that came out of the discussions that we had:

  • As much as overlapping partnerships are riskier than sequential partnerships, youths still prefer them because they are interesting and “make life worth living.” They believe there is adventure in trying to conquer and have new relationships that are more interesting than the one they are in.
  • Sequential relationships are the best option. But after leaving (or being left by) a lover, it can be hard to wait a long time to start a new relationship, because you might be hurting and wanting to be with someone for emotional and psychological reasons.
  • Young women say they need different men in their lives to do different things for them, namely one for dating, one for financial support, one for one-night stands, and another as a full-time lover.
  • If you are in relationships with a lot of people at once, the chances of being hurt are slim because you have not fully invested feelings in only one person. Then, if a relationship with one of your lovers becomes stressful, it is much easier to leave and move on to another one on the list.
  • Youth feel that when one gets into a relationship with someone, they know them inside out. This leaves no space for new discoveries, and having the same routine over and over again sometimes becomes boring. One tends to want to have that feeling of first love and pursuit rekindled.
  • Young women say that since men will never be satisfied with one person, it’s only fair for women to also have someone else or other relationships on the side just to be safe in case the men leave them for “greener pastures.”

As you can imagine, the discussion was long and heated. Many youth were aware of all the risks involved but still had difficulty seeing themselves with just one partner. The most important thing they took away from the discussion was that if you will not be in just one relationship at a time, then you must have full knowledge about how to protect yourself from various risks that are involved with having an overlapping relationship.

The “use condoms” tune had to be sung again, as well as the need for testing and counseling. The good thing about the activities we tested is the fact that they do state exactly what is going on in our lives today. They bring something fresh to the table and can help equip youth with the knowledge and information needed for sound decision-making.

Robyn Dayton is a Technical Officer at FHI where she works on the research utilization portfolio of youth reproductive and sexual health activities.

I recently traveled with an FHI colleague, Allison Prickett, to Kenya and Botswana to test a new set of activities that were designed to prevent multiple and concurrent partnerships (MCPs) among youth.  For more information on our trip and the health impact of these sorts of partnerships see Allison’s blog entry from March 7, 2011.

What struck me most in the field tests is just how common these kinds of partnerships are and how complex and difficult it will be to change this behavior.  Even as they acknowledged how dangerous MCPs can be, the youth we spoke to described the need for having multiple sexual partners at one time.  We heard often that young people believe it’s impossible to get what one needs from just one sexual partner.  For example, young women talked about having one financially supportive partner, commonly called a sugar daddy, and a partner who is closer to her age—someone with whom she has a romantic connection.  Young men reported that having two or more sexual partners is a symbol of status.  Furthermore, both young men and women see additional partners as a way to deal with the loneliness that results from being in long-distance relationships, which are quite common. And even when a couple lives together, the perception is that having additional partners means greater sexual satisfaction.

So, what to do?  Should we encourage youth to reassess need versus desire, even if this means attempting to change culture (especially those cultures that have historically promoted polygamy or that continue to)?  Do we teach youth to focus on finding new ways to get their needs met without additional partners? If so, maybe we should work on income-generating activities to help alleviate the need for sugar daddies, or teach communication skills so that youth can talk to their main partner about their sexual desires instead of going outside the relationship when they want to try something new.  Should we try to help youth have safer concurrent partnerships—ones in which they use a condom 100% of the time with every partner, even those they have been with for years?

Luckily, the power of field testing activities comes not only from learning what the fundamental questions are, but also from learning who might have the answers.  The youth in the field tests were actively engaged in answering the questions above for themselves.  And ultimately, it won’t be up to curriculum developers to determine the best way for youth to deal with these fundamental issues—the answers have to come from the youth themselves. Otherwise, how relevant and acceptable could these answers be?

Allison Prickett, MPH is a Global Health Research Fellow at FHI.

At Stepping Stones International (SSI), located just outside of Gaborone, Botswana, children gather every day for an after-school program that includes activities such as tutoring, life skills lessons, and a meal. In Botswana, 17 percent of the population is living with HIV and 64 percent of children ages 10-18 have been left orphaned by the epidemic. SSI provides a safe and nurturing environment where orphaned and vulnerable children can gain the skills they need for a bright future.

Just a few weeks ago, I had the opportunity to work with FHI colleagues from North Carolina and Botswana as we partnered with SSI to pilot-test educational activities pertaining to HIV. Much of the HIV epidemic in Botswana is attributed to the social norm of having multiple and concurrent sexual partnerships (MCPs), locally known as having “a small house.” MCPs are particularly dangerous for a couple of reasons. When someone first becomes infected with HIV, that person has a high viral load, meaning they are highly infectious and are much more likely to rapidly spread the disease to their partners. And secondly, by their nature, MCPs create a large sexual network through which the virus navigates. The government of Botswana recently initiated a campaign, O Icheke, designed to raise awareness and change behavior related to MCPs. However, most HIV programs worldwide do not currently address MCPs as a key driver in the spread of the virus.

Given the high prevalence of HIV and the active role the country’s government has taken in HIV prevention, Botswana made for a prime location to pilot-test seven activities that are geared toward informing youth about the dangers of MCPs. These activities were collaboratively created by ETR’s Doug Kirby and by FHI. The activities are meant to supplement an existing HIV educational program, because they focus specifically on building knowledge, values, and skills that youth need to make healthy decisions about sexual partnerships.

Pilot-testing at SSI proved to be not only beneficial for improving the MCP activities, but also a great deal of fun with the participatory lessons, discussions, and role-plays. The participants were intrigued and eager to share their newly acquired knowledge with their peers. With input from SSI’s staff, we hope to refine these innovative educational activities on MCPs to help combat the spread of HIV.

For more information, check out the links below:

Stepping Stones International

The O Icheke Campaign, Botswana (707 KB)

FHI is field-testing a new set of activities that teach youth about the risks of multiple and concurrent partnerships (MCP) and encourage positive behavior change.  These activities will be used to supplement existing sexuality education or life skills education programs.  In this slide show, peer educators in Kenya use the activities to discuss MCPs with a group of young adults.  Feedback from the peer educators and participants in Kenya and in two other countries will be used to improve the activities before they are published.

View our slide show!

In a well-off suburb of Johannesburg, South Africa, a bride-to-be listens to the radio as she happily dresses for her wedding, until an announcement stops her cold: a popular local DJ—whom she had dated five years earlier—is dying of an AIDS-related illness. Now she must decide whether to tell her groom of her previous relationship or keep her past, and her possible infection, to herself.

This scene opened the new South African television drama Intersexions, a series of 25 vignette-like episodes that tell independent but connected stories of people infected with and affected by HIV. The series offers a window into the characters’ relationships and the circumstances of their infections, following the spread of HIV within a sexual network across age, race, sexual orientation, and socioeconomic status. Each episode sheds more light on the interconnectedness of sexual networks and spurs viewers to reflect on the potential consequences of multiple and concurrent partnerships within their own networks.

Intersexions, sponsored by Johns Hopkins Health and Education in South Africa (JHHESA) has been wildly popular in South Africa. October’s opening episode was watched by more than half of all television viewers in South Africa, and by December, Intersexions had become South Africa’s most watched drama series and the second most watched television show overall on the South African Broadcasting Corporation (SABC). The show’s Web site includes a link to Ask the Dr., a space where anyone can submit a comment or question to Dr. Elna McIntosh, a licensed sexual health care practitioner. The site also contains a Radio Schedule, so audience members can tune into the weekly discussions on various radio stations around South Africa which support Intersexions episodes by focusing on themes raised in that week’s episode.

Have you seen Intersexions? Let us know what you think! Click here to learn about JHHESA’s other radio and television shows on love, sex, and health.

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This blog is brought to you by the Interagency Youth Working Group (IYWG) with financial assistance from the U.S. Agency for International Development and the U.S. President's Emergency Plan for AIDS Relief. The content is managed by FHI, which functions as the secretariat for the IYWG.
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