HIV and cohabitation
Here is something from Fungai Machirori, one of Zimbabwe’s best social commentators:
It’s just you and me … and my wife and your boyfriend…
This might sound like a humorous line. But in Lesotho, one of the world leaders in prevalence of HIV, this is the name of a play that has been developed to address the issue of multiple and concurrent partnerships (MCP).
And this play was one of the innovative interventions shared at the Africa-wide practicum on HIV prevention among married and cohabiting couples in Africa, held from 11 to 13 August in Johannesburg, South Africa. The three day-long meeting which brought together over 100 HIV and AIDS communications experts from almost 20 African countries was organised by the African Network for Strategic Communication in Health and Development (AfriComNet).
In his opening address the guest of honour – South African National AIDS Council (SANAC) Communications Advocacy and Campaigns Manager, Junaid Seedat – underscored the importance of looking at HIV transmission among married people and those involved in stable relationships by citing regional statistics on a growing epidemic that is hardly ever discussed or addressed.
Kenya, around 40% of new HIV infections are happening among married women while in Uganda, about 65% of new HIV infections are found in cohabiting couples,” said Seedat, quoting national data from both East African countries. He also cited a 2008 Cape Town study that demonstrated that people involved in MCP were using condoms only 64% of the time within their stable relationships.
The practicum focused on various communication challenges and interventions such as couples’ HIV status discordance, behaviour change communication, couples HIV counselling and testing and condom use.
“Some people don’t think that communication matters and some people want to resort to an entirely medical approach to HIV,” observed international HIV and AIDS expert, Helen Epstein who delivered the practicum keynote address. “But I think it would be a mistake to give up on communication completely.”
During the practicum factors such as sexual dissatisfaction (lack of variety in sex positions, infrequent sex or no sex at all), lack of communication between partners and male entitlement to multiple partners were discussed as some of the drivers of MCP in some regions of Africa. Such concurrency, coupled with low condom use, is currently a high-risk factor for HIV transmission.
Bisexual concurrency among men who have sex with men (MSM) was also noted as a driver of HIV by Gift Trapence of the Centre for the Development of People in Malawi. In a three-country study conducted in Botswana, Malawi and Namibia, overall rates of HIV infection were found to be about double national prevalence estimates for all men of reproductive age.
As noted by Churchill Alumasa of the Discordant Couples of Kenya, one of the challenges to people involved in stable relationships in knowing their status is what he described as ‘proxy testing’ whereby one partner bases their HIV status on that of their partner’s.
Evidence shared at the practicum shows that a couple that has been sexually active can maintain different HIV statuses. But early detection, through regular HIV testing is key to ensuring that the HIV negative partner remains negative and that the couple takes up consistent and correct condom use throughout the rest of their sexual relationship.
One of the challenges to this as shared by many of the speakers at the practicum is that models of couples testing across the continent tend to focus on bringing couples together to testing centres and yet thereafter, each member of the couple is tested separately thus providing leeway for an HIV positive partner to disclose a false status to their partner. For instance, Professor Susan Allen of Pathology and Laboratory Medicine and Global Health, shared that routine testing for partners of pregnant Rwandan women increased from 40% in 2006 to 80% in 2008, but that women and men were tested separately.
Allen added that regular couples testing had a significant cost advantage over the recently mooted ‘test and treat’ policy that seeks to treat all people found to be HIV positive (thereby making them less infectious to people who are HIV negative) and would actually prevent far more new infections thus putting less financial strain on the treatment end of the spectrum.
Allen’s data showed that in Zambia, it would cost USD 675 000 per year to prevent 70 new infections among 1 000 serodiscordant couples. But yet that same amount of money could provide couples HIV counseling and testing to 10 227 more couples preventing 285 infections in one year, and a cumulative 1282 infections in five years.
Religion and cultural norms were also identified as barriers to effective uptake of services. A study conducted by Zimbabwe’s Family AIDS Caring Trust (FACT) presented by Pemberai Zambezi showed that among members of the Johane Marange Apostolic Church, many refused to acknowledge the existence of HIV in the belief that one could pray for healing from the virus. Such denialism was suggested to be particularly dangerous for this group as evidence shows that their previously clustered and closed sexual networks, developed through practices such as polygamy, child pledging and wife inheritance, are now also becoming multi-linked as partners seek sexual relations outside of their closed unions.
But while the experts shared their promising practices, they also shared some of the obvious challenges inherent in their programmes; for instance, the strong emphasis on love in many of the communications interventions shared. These included couples testing campaigns such as ‘Prove Your Love’ in Mozambique and ‘Keep Your Love Under One Roof’ in Zimbabwe. This, many participants felt, left a grey area for those involved in sexual relationships who did not identify themselves as being in love with their partner.
However, it was agreed that often government influence, from whom buy-in must be guaranteed if a campaign is to be successful, led to organisations having to moralise sex and therefore censor their content to gain government’s favour. For instance, due to government pressure and displeasure, Uganda’s ‘Get Off the Sexual Network’ Campaign had to withdraw the use of children highlighting how their parent’s concurrent sexual partnerships had destroyed their family life.
Another obvious challenge shared was funding to ensure sustainability of programmes. One stark example of this was Zambia’s OneLove Kwasila! campaign which achieved overwhelming success particularly through its television drama, ‘Club Risky Business’ depicting the lives of three men all involved in MCP. The campaign’s theme song was a Zambian Top 10 hit showing that the campaign had not only served its communication functions to inform and educate, but also to entertain. The campaign has however been unable to replenish funds to enter into the second phase of the intervention.
Also consistency and uniformity in messaging was identified as a barrier to audiences understanding communications efforts. For example, participants could not reach consensus among themselves on the meaning and parameters of serial monogamy – a sexual practice which was suggested as being far less conducive to accelerated HIV transmission than MCP. It was also suggested that reference to HIV counselling and testing as either HCT or HTC, depending on the region of Africa, made it confusing for people to always understand what was being discussed.
Recommendations offered at the end of the practicum were for such AfriComNet to include private sector players who might be able to engage in public-private partnerships with civil society and government, in future editions of the event. It was also suggested that AfriComNet facilitate capacity building exchange visits between countries and programmes, while also creating a clearing house for HIV and AIDS materials on its website. The need for AfriComNet, whose secretariat is currently located in Uganda, to establish regional secretariats was also emphasised.
Source: AF-AIDS List