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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.”

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

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.

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


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

At the height of the U.S. “AIDS crisis” in the late 1980s and 90s, I was a college student volunteering at Planned Parenthood in upstate NY. At that time, I could not imagine that I would end up in South Africa working with HIV youth programs more than 20 years later.  But, that’s exactly where I was a few weeks ago. 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 resource developed by FHI 360, Promoting Partner Reduction: Helping young people understand and avoid HIV risks from multiple partnerships (PPR).  This was my first trip to Africa, and although my role was to provide training to the participants, I am the one who learned something. If you have ever traveled to South Africa, you know the countryside is awe-inspiring, the historic struggles for freedom are still apparent and the people are warm and welcoming. But, my experience also served as a reminder of the path that brought me to this point and may resonate with you, as well.

Like most public health professionals, the reasons I entered this field were noble. I was an enthusiastic college student being introduced to public health at a very exciting time. I felt like I was making a difference.  I did street outreach; gave out condoms in gay bars, bus stops and hair salons; I led HIV prevention programs in prisons, low-income housing communities and clinics. This is the same kind of work that the participants who attended my training are doing in South Africa and Swaziland now. But times have changed, HIV rates in the U.S. have dropped dramatically and I fear that many people think that AIDS is no longer “our problem”(of course, we know that is not true). Things have changed for me, too. Now, I sit in a third floor office of a mirrored building at FHI 360 headquarters in Durham, NC.  I attend international conferences and work with some of the most influential public health leaders in the world, yet my trip to South Africa reminded me of why I continue to be inspired by this work.

At the end of my trip, I had the opportunity to spend a day with loveLife staff and program participants in Orange Farm, an informal settlement outside Johannesburg.  Orange Farm is the biggest and most populous informal settlement in the country, home to nearly 350,000 people—mostly living in shacks, often unskilled, scraping out a living day-to-day. But, I saw a much different side of Orange Farm. Unlike other informal communities, which consist largely of dilapidated dwellings, many shacks in Orange Farm are well-maintained and colorful, with tidy gardens. Despite their circumstances, the residents clearly take pride in their community. I had the opportunity to visit loveLife programs at a clinic, local school and youth center.  At the youth center, I met peer educators (called “groundBreakers”) with that spark in their eyes. You know the spark: you’ve seen it and perhaps experienced it. I know I have….it’s the belief that you alone can change the world. Here they are, living and working with limited resources and innumerable obstacles and yet, they are not daunted by the task at hand. Like the rest of us in the HIV prevention world, their goal is to contribute to an HIV-free generation, not just in Orange Farm, across South Africa or Swaziland, but globally. They are doing their part, and they reminded me that I am doing mine.

The truth is, we can all benefit from a reminder every now and then. I came back to my office reinvigorated, inspired and motivated to continue to support programs in developing countries with the tools that will help them do their daily work: educating and inspiring young people the same way I did on the streets, in the bars and clinics so many years ago. I was reminded that we all have a role to play. It’s easy to become complacent or to sit in my comfortable office wondering if what I am doing even matters. But, the reception I received from the youth program staff in South Africa told quite a different story. They were desperate for new resources and excited to have the opportunity to learn. Although I was there providing training and technical assistance to them, I am the one who returned with an education. After 20 years of working with public health programs in the U.S., the two weeks I spent in South Africa will forever change my perspective.  On some level, I feel like I have come full circle from my volunteer days at Planned Parenthood but on the other hand, I don’t feel like I’ve changed at all. There is still much work to be done, both from my third floor office and on the streets of communities like Orange Farm…and only by working together do we stand a chance of reaching our common goal of an HIV-free generation,”

Next week, Marta will share more about the training and the lessons she learned about young people and multiple concurrent partnerships.

Robyn Dayton is a technical officer on FHI 360’s Research Utilization Youth Team.

Many people, this blogger included, work to create new tools for youth HIV prevention. The result— depending on which listservs you subscribe to—could be news about a new tool in your inbox each week (if not each day). 

And quite often, these tools seem extremely useful. But do we know what happens to them after they are sent out into the wide world of the Internet or after hard copies get shipped across the globe? Are the tools we are creating being used? By whom? And, even more importantly, are they making a difference?

FHI 360, with support from USAID’s IYWG, had the opportunity to find out how tools it published to improve HIV counseling and testing services for youth—both a manual for providers (2007) and the associated training guide (2008)—have been used since their release. We were able to talk to users of these tools from all over the world, and we were happy about what we heard. People not only really like these tools (96% of respondents reported satisfaction) and share them (reported by 70% of respondents), they learned from them (almost 100% reported increased knowledge) and changed the services they offered because of them (75% reported changed behavior in clinics). Check out some of their quotations below to get a sense of what else people had to say.

“In Indonesia, there is homophobia. After the manual I no longer judge young people based on this [sexual orientation].” – Indonesian service provider

“At first, before training, I thought of youth as drug users, bad people, now very big friends, nice people who can be used to do good things.” –Kenyan HIV counselor

“Before I was trained, for example, if the youth came out positive I would even scold them – ‘you are misbehaving.’  But after training, I take into consideration their risk behaviors and now I understand what they go through.” –Zambian nurse

What’s more, the impact of these tools goes far beyond individuals—these resources have had an impact at the national level. The manual informed the national policy on HIV counseling and testing in Guyana and was used to create a national curriculum for health providers in Botswana. For the past four years, it has been in use across Zambia to train both nurses and HIV counselors to improve their interactions with young clients. (How these tools are used in Zambia and what program staff have done to make global tools more locally relevant will be described in an upcoming blog post.)

As anyone who has created something they hoped would benefit others can imagine, it was inspiring to learn how these tools have been used and the impact they have had. It was also very informative.  We found out which parts of these tools were most helpful, how to make new resources more useful, and how best to get tools into the hands of those who will most benefit from them. Since we were talking directly with people who provide HIV testing to youth, we also got their take on what else is needed— things like support groups for the adolescents they give positive HIV results to—that provide information about what’s necessary in the next generation of tools. 

So, whether it is for your own sense of purpose, or because you know that future products will be that much better for it, try to learn what happens after you press “send” on that new tool you’re creating.  Feeling inspired to do HIV prevention work is vital, and what can be more inspiring than hearing something like this from a young person in Zambia who encourages other youth to get tested at his clinic: “After the training on the manual everything changed. We’ve managed to overcome stigmatization — not just in clinic but in the community.  We are also making our activities better. Our office is always busy now with lots of youth.”

This post was written by FHI 360’s Tanzania field office staff.

A Swahili tradition—initiation of young women into adulthood—has long served as a vehicle for older women to pass on reproductive health knowledge and skills. Swahili families hire traditional “initiators” (manyakanga) to lead small groups of young women through several days of training on puberty, sex education, and the roles of husbands and wives. The initiation culminates with a celebration attended by hundreds of community members.

Young women in Tanzania, as elsewhere, face a disproportionate threat from HIV and AIDS, and reaching them in creative, effective, and culturally-acceptable ways is increasingly important. To address this need, PEPFAR has funded a groundbreaking pilot activity through FHI 360’s youth-focused UJANA project, which employs a range of innovative HIV prevention methods. Implemented through a local nongovernmental organization, Partnership for Youth Development (PAYODE), 21 manyakanga and a group of musicians who lead the graduation ceremonies were trained on HIV prevention and supported to integrate HIV prevention education in the initiation teachings and ceremonies.

Girls ranging in age from 10 to 18 were initiated by trained manyakanga. Both younger and older women praised the training they received. Asma, 14, says, “We spread all the good information we learned. Our friends wish they had done the same initiations. They missed something important.”

The chairperson of the manyakanga group, Blandina Mbagi, concurs, “I wish my young girls could have known all these things before. There is a big, big difference between girls who go through our initiations and girls who go through other initiations. These ones know the risks; they become careful.”

Community members and local government authorities praise the use of culturally grounded methods for imparting HIV education, rather than attempting to eliminate a valued practice. This integrated approach, as manyakanga Amina Sadiki points out, means that “Now we give them our cultural values together with an HIV component.”

There are so many amazing organizations out there dedicated to improving the lives of young people. At the IYWG, we love connecting with these organizations, whether it is through Facebook, Twitter, email, or through our blog. Just the other day, we received an email from Treasureland Health Builders, a youth reproductive health and economic empowerment NGO in Nigeria. We were thrilled to hear from them! They also sent us some great pictures of the work they are doing:

Thanks, Treasureland, for the amazing photos!

If you want to connect with the IYWG, visit our Web site, sign-up for our blog (on the left of this page), follow us on Twitter, like us on Facebook, or e-mail us; we will be happy to hear from you!

At the IYWG, one of our major activities is producing and disseminating publications and tools that advance the sexual and reproductive health of youth. That is why we are always happy to hear from organizations that are using our materials!

Recently, we sent a shipment of our Muslim family life education curriculum to the Kenya Muslim Youth Foundation. After receiving the copies, they graciously shared with us quotes of their colleagues’ reactions and photos from the dissemination. We were so excited, we thought; “why not share this with our blog readers as well?”

“The book is very interesting, particularly to the Muslim youth. The book has specified the roles both male and female youth could play to avoid idleness; this prepares them for the responsibilities ahead of them when they will marry and have children.”

“Indeed, it is a good book that will be used by our facilitators during our workshops.”

Thanks again to Kenya Muslim Youth Foundation for sharing these photos!

To view the Muslim family life education curriculum, click here.

To learn more about faith-based programming for youth sexual and reproductive health, visit our faith-based program area page.

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!

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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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