Public Affairs Section

Addressing Multiple, Concurrent Partnerships and Cross-generational/Informal Transactional Sex:

Programmatic Models for HIV Prevention

A Resource Document for PEPFAR Country Programs

General Population and Youth HIV Prevention Technical Working Group

President’s Emergency Plan for AIDS Relief
Office of the U.S. Global AIDS Coordinator

July 2007

Compiled by:
Melissa Poulsen, MPH
Linda Wright De Agüero, PhD, MPH
 
Introduction

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) supports the rapid scale-up of prevention education and services.  Among the greatest challenges to mounting effective prevention programs is the diversity of epidemic contexts and prevention needs across countries.  In generalized, high prevalence epidemics, many new infections result from multiple, often concurrent sexual partnerships and informal transactional sex within the general population.  Often, individuals in such relationships do not see themselves as engaging in high-risk behavior.  These behaviors are believed to be one of the key drivers of the HIV epidemic in sub-Saharan Africa, especially among young women, who have disproportionately higher HIV prevalence rates when compared to men of similar age groups. 

Multiple, concurrent sexual partnerships

While men and women in Africa have similar, if not fewer, numbers of lifetime partners than in other regions of the world, it has been observed that they often have multiple concurrent partnerships that can overlap for months or years.  These relationships often evolve into trusted partnerships over time, with consistent condom use declining substantially. In terms of the impact on HIV transmission, concurrency has been argued as riskier than the patterns of serial monogamy or one-time casual and commercial sexual encounters (where condom promotion has been more successful) because it involves complex chains of interconnected partners that place an entire network at risk. The risk of concurrent partnerships may be compounded for members of the sexual network when newly infected persons, who experience a spike in viral load during the acute infection phase, remain sexually active.  

Effective programs that address partner reduction and promote fidelity to one sexual partner are greatly needed. Such interventions have historically taken one of several approaches, including:
 Encouraging healthy behavioral choices and emphasizing personal responsibility and long-term goal setting
 Improving couples communication
 Changing social norms to encourage mutual monogamy
 Encouraging and providing individual and couples counseling and testing
 Challenging traditional gender norms and definitions of masculinity
 Increasing risk perception, addressing “trusted partner” myths, and building knowledge about sexual health
 Using condoms with sexual partners who are HIV positive or of unknown status
 Reducing alcohol use that increases risky behavior

Although a variety of programmatic approaches have been developed to address partner reduction, there are few that discuss the specific risks of concurrence and acute infection as a core component of an intervention.  The development and communication of risk reduction messages on concurrency and acute infection is a challenging, but much needed, component for prevention programming in generalized epidemics.

Cross-generational and informal transactional sex

The disparity in the levels of HIV infection between men and women—especially in countries in sub-Saharan Africa—is of great concern. Particularly among youth and young adults, many more girls are infected than boys. According to the WHO, young women aged 15-24 are three to four times more likely to be infected than young men of the same age. One explanation for this disparity in infections is age-mixing in sexual relationships between older men and young women. Older men have higher rates of HIV than young men, and relationships with older men limit young women’s power to negotiate safe sex , particularly since there is often transactional exchange of money or gifts for sex. The socioeconomic and power imbalances inherent in cross-generational and transactional sexual relationships put young women at high risk of unintended pregnancy and sexually transmitted infections, including HIV.

Interventions targeting cross-generational/transactional sex are challenging, as they must ultimately address the power and economic inequities that foster these relationships. The main approaches to addressing this issue include :
 Skills-based HIV and sexual educations programs
 Programs centered around empowering girls and young women to adopt healthy behaviors
 Social advocacy and awareness raising in order to change social norms
 Health education, social marketing, and “edutainment” to increase knowledge, awareness, and risk perceptions
 Promoting condom use with non-marital, non-cohabitating partners
 Vocational training and sustainable livelihood programs which provide girls and women with economic skills and opportunities
 Addressing power imbalances, inequity, and poverty
 Addressing gender norms and male responsibility

Addressing the issues of partner reduction and cross-generational sex are a priority for many of the PEPFAR focus and non-focus countries. Effective programs are needed that can be adapted and scaled-up in a variety of settings.
 
Overview

The purpose of this document is to describe program models that can serve as examples to countries that are interested in implementing programs to address the issues of concurrent partnerships or cross-generational/transactional sex. Rather than developing new program models, countries may be able to save time and resources by adapting pre-existing programs to their settings and populations or by using these models as a theoretical foundation from which to build their own programs.

This document is an initial effort to quickly gather examples of programs that can be shared with countries interested in reexamining their HIV prevention portfolio to address the issues of partner reduction and cross-generational/transactional sex. The programs that are included come from recommendations by members of the General Population and Youth HIV Prevention Technical Working Group. A more exhaustive and systematic search for program models to address these two issues is planned as a future activity.

This document is comprised of two sections: Section 1 includes programs that address multiple, concurrent partnerships and Section 2 includes programs that address cross-generational/transactional sex. A summary of each program describes the components that countries may find useful in deciding whether a particular program is appropriate for their needs. This includes:

 Background information about the program, including: the country that first implemented the program; the organizations responsible for funding, developing, or implementing the program; the date the program first started; and who to contact for more information on the program.

 Evidence, theory or idea on which the program is based. This is done by assigning the program to one of the following three categories:
o Evidence-based: the program has been evaluated and found to have a significant effect on relevant biological or behavioral outcomes
o Theory or Formative-based: the program is based on behavior or social change theory, comprehensive logic model, formative research, or positive process evaluation data
o Promising idea: the program is newly developed and/or has not been evaluated to determine positive process data or biological or behavioral outcomes

 Descriptive information, including: program type; main focus of the program; target population; venue in which it was delivered; major components or activities of the program; materials used to run the program; and a brief description of the program.

 Core elements of the program are listed when possible. These are elements which must be kept intact during the adaptation process in order for the program to be effective.

Behavioral Determinants

Understanding the behavioral determinants of risky behaviors such as cross-generational/transactional sex or having multiple sex partners is necessary for developing effective interventions. The resources described below are useful for program planners to gain an initial understanding of these two issues.

Multiple, Concurrent Partnerships:

 Shelton JD, Halperin DT, Nantulya V, Potts M, Gayle HD, Holmes KT. Partner reduction is crucial for balanced “ABC” approach to HIV prevention. British Medical Journal. 2004; 328: 891-893.

 Morris M, Kretzschmar.  Concurrent partnerships and the spread of HIV. AIDS. 1997; 11:641-48.

 Wilson D, Epstein H. Concurrent sexual partnerships help to explain Africa’s HIV prevalence: implications for prevention. The Lancet. 2004; 364(9428):4-6.

Cross-generational/Informal Transactional Sex:

 Luke N & Kurz K. Cross-generational and transactional sexual relations in sub-Saharan Africa: Prevalence of behaviour and implications for negotiating safer sexual practices. Washington DC: ICR & PSI. 2002.

 Weissman A, Cocker J, Sherburne L, et al. Cross-generational relationships: Using a ‘continuum of volition’ in HIV prevention work among young people. Gender and Development. 2006; 14(1): 81-94.

 Dunkle KL, Jewkes RK, Brown HC et al. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Social Science and Medicine. 2004; 59(8):1582-1592.

 Gregson S, Nyamukapa CA, Garnett GP et al.  Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. The Lancet. 2002; 359(9321):1896-903.

The following paper, a desk review commissioned by the USAID Bureau for Global Health, details the range of programmatic approaches available to prevent or reduce cross-generational sex. It describes numerous programs targeting cross-generational sex, some of which are summarized in this document.

 Hope R. Addressing Cross-Generational Sex: A Desk Review of Research and Programs. (June 10 2007.)

Section 1

Program Models to Address
Multiple, Concurrent Partnerships 
(Status of project as of May 2007)

Implementing Country:
 Originally implemented in Uganda
 Adapted and used in over 40 countries
 Evaluated in South Africa

Developers:
Strategies for Hope

Date Started: 1995

Evidence-based:
A cluster randomized control trial by the Medical Research Council of South Africa showed a reduction in the number of partners in men
(Jewkes et al, 2006)

Program Type:
Participatory education

Focus:
 Gender equity
 Communication skills
 Sexual risk-taking and decision-making about sexual behavior

Target Population: Adults and youth

Venue: Community settings

Components:
 Small-group workshops

Materials:
 Training manual
 Adaptation guidelines 

For more information: http://www.steppingstonesfeedback.org/index.htm

Program Description:
Stepping Stones aims to improve sexual health through building stronger, more gender-equitable relationships with better communication between partners. It uses participatory learning approaches to build knowledge of sexual health, awareness of risks and the consequences of risk taking and communication skills, and provide opportunities for facilitated self-reflection on sexual behavior. Workshops aim to enable women and men of all ages to change their behavior through the ‘stepping stones’ which the various sessions provide. The 18 program sessions are delivered to small groups of the same gender and age over 10-12 weeks. Occasional sessions bring everyone participating in the program together to share experiences and find common ground.

Core Elements:
 Four main themes: group cooperation, HIV and safer sex, why we behave in the ways that we do, ways in which we can change
 Participants use their own experiences to find their own solutions to problems
 Participants work in peer groups with whom they feel comfortable—for example, with people of the same gender and similar age group
 Facilitators guide and support, provide information as it is needed and challenge ideas, but do not tell people what they should do or judge them

Resources:
 Jewkes R, Nduna M, Levin J, et al. A cluster randomized controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behavior amongst youth in the rural Easter Cape, South Africa: Trial design, methods, and baseline findings. Tropical Medicine and International Health. 2006; 11: 2-16.
 
(Status of project as of May 2007)

Implementing Country: Tanzania

Developers:
USAID
Academy for Educational Development
Tanzania Marketing & Communications Company (T-MARC)

Date Started: March 2007

Promising Idea:
 Based on the Uganda experience where the promotion of partner reduction was identified in the reduction of HIV
 Evidence will be collected via KAPB study in late 2007

For more information contact: Hally Mahler
Email: hmahler@tmarc.or.tz

Program Type: Multi-channel communications campaign

Focus:
 Partner reduction/faithfulness

Target Population:
Adults (18-49), particularly in communities with high HIV rates

Venue: Community-based settings

Components:
 Peer education and messaging by community influentials
 Organized entertainment events
 Community mobilization
 Multi-media campaign (radio ads and other media)

Materials:
 Small media materials
 Giant bell 

Program Description:
Sikia Kengele (Listen to the Bell) is a multi-channel communications campaign whose purpose is to encourage people to change their sexual behaviors through partner reduction and being faithful. The campaign is driven by Bell Ringers—community influentials such as politicians, religious leaders, and community health leaders, as well as peer educators–who are charged with initiating conversations on the dangers of having multiple sexual partners and the benefits of remaining HIV-negative. This is implemented through day-to-day interactions and organized group events in venues such as bars, stadiums, mosques, churches, farms, and bus stations. “B” messages are tailored to the population being addressed. Bell Ringers also prepare communities for the Giant Bell, a road show (and large bell) which travels to communities with a high profile team of influentials and educators that use music, dance, dramas, and cinema to positively influence people to reduce the number of sexual partners.  Supportive radio spots are aired nationally to promote the benefits of faithfulness and prepare communities to be open and motivated to implement the Kengele initiative.

Core Elements:
 Concept of a wake-up call
 Examination of community norms both from interpersonal communication and larger community dialogue
 The use of influentials to promote dialogue
 Supportive media to familiarize the population with the initiative
 
(Status of project as of May 2007)

Implementing Country: Uganda

Developers:
USAID
John Snow Incorporated
UPHOLD Project
TUKO club with Office of the First Lady

Date Started:
February 2006 – April 2007

Promising Idea:
Program assessment planned

For more information contact:
Samson Kironde
(Chief of Party, UPHOLD program)

Program Type:
Peer education and support

Focus:
 Mutual faithfulness
 Couples counseling and testing

Target Population: Married couples

Venue: Community-based settings and households

Components:
 Training of “model couples” as peer educators
 Couples counseling and support

Materials:
 Motivational materials for model couples (t-shirts, bicycles)
 Training manual on faithfulness 

Program Description:
This intervention promotes mutual fidelity among married couples by training “model couples” as peer educators to work with communities and households to support couples in knowing their HIV status and making an informed decision to be mutually faithful.

Core Elements:
 Discussion of faithfulness by couples
 Advocacy and facilitation for couple support groups
 Community dialogue sessions on faithfulness
 
(Status of project as of May 2007)

Implementing Country: Uganda

Developers:
USAID, JHU Health Communication Partnership, Young Empowered and Healthy (YEAH) Initiative, Uganda AIDS Commission

Date Started: July 2006

Promising Idea:
 Uganda sero-behavioral survey 2004-05 shows that men have multiple partners much more often/common than women
 Trend analysis shows that multiple partners have steadily increased between 1995-2005, esp. among men

For more information contact:
Sereen Thaddeus
Email: SThaddeus@usaid.gov

Program Type: Social marketing and interpersonal approaches

Focus:
 Male gender norms

Target Population:
Men in male-dominated workplaces, uniformed services, schools, athletics, and community groups

Venue:
Community-based settings, including workplaces, schools, and military bases

Components:
 Interactive workshops
 Media campaign
 Positive role models

Materials:
 TV spot (see web link below)
 Training curriculum
 Radio drama 

Program Description:
This program incorporates interactive workshops for men in various community-based settings with the purpose of stimulating introspection and discussion about masculinity and the male gender norms that put young people and married couples at risk of HIV. For the media portion of the program, B a Man television spots were aired during broadcasts of the 2006 World Cup and shown on Ministry of Health “film vans” that toured rural communities.  Be a Man attitudes and behaviors are defined throughout the training, discussions, and modeled through the media materials, including the radio drama serial RockPoint 256.  This program is directly linked to the YEAH Initiative campaign Something for Something Love, which addresses cross-generational sex.

Core Elements:
 Modeling for behavior change
 Male to male approach
 Faithfulness, partner reduction for HIV prevention

Resources:
 TV spot: http://www.hcpartnership.org/Programs/Africa/uganda/yeah.php 

(Status of project as of May 2007)

Implementing Country: Botswana

Developers:
CDC, Pact, Population Services International, Humana People to People, African Methodist Episcopal Services Trust (AMEST)

Date Started: June 2006

Theory or Formative-based:
 Program designed based on results of survey data (PSI 2005)
 Needs assessment in community completed prior to implementation
 Project monitoring planned

For more information contact: Marion Carter
Email: CarterM@bw.cdc.gov

Program Type:
Multi-faceted intervention

Focus:
 Fidelity and partner reduction
 Risk perceptions relating to alcohol and sex
 Couples counseling and testing

Target Population:
 Secondary school students
 Adults of reproductive age (18-34)
 Community and religious leaders

Venue: Community-based settings, FBOs, drinking establishments

Components:
 Media campaign (TV, radio, print)
 Community-based outreach activities

Materials:
 Training curricula
 Peer education support materials
 Media materials 

Program Description:
This project uses mass media activities to address “trusted partner” myths, promote fidelity and HIV testing, and increase risk perceptions related to mixing alcohol and sex. It also uses a range of community based outreach activities such as “edutainment” and using peer educators and community role models to sensitize the community to these issues. The campaign also involves improving the capacity and motivation of FBO leaders to discuss fidelity and provide life skills to youth in order to address cross-generational sex, casual sex, and fidelity. Trained Field Officers are also used to motivate community leadership and create community forums to address partner reduction and risky drinking, including conducting peer education in drinking establishments.

(Status of project as of May 2007)

Implementing Country: Botswana

Developers:
Pact; Various local FBOs, CBOs, and NGOs; Consultant Iain McLellan

Date Started: October 2006

Theory or Formative-based:
 Organizational assessments
 Pre-testing of materials

For more information contact: Marion Carter
Email: CarterM@bw.cdc.gov

Program Type: Peer education

Focus:
 Sexual behavior choices
 Couples communication
 Multiple partnerships
 Cross-generational sex

Target Population:
Young adults (singles and those with partners)

Venue: Community-based settings

Components:
 Visual aids to stimulate discussion during peer education sessions

Materials:
 Picture codes and flipcharts 

Program Description:
Pact has overseen the development of flipcharts and picture codes to be used by various peer educators supported under its prevention grants program.  The materials complement curriculum-based activities. These visual aids stimulate discussion about couples communication (including: fidelity, alcohol use, domestic violence, male norms, HIV testing) and sexual behavior choices (including: fidelity, consequences of unprotected sex, abstinence, transactional sex, family communication).  The materials were developed collaboratively with the local implementing partners, in response to a clear need for more peer education support materials. The picture codes include sets of color photos of stimulating scenes, with discussion questions and key messages on the back for peer facilitators.   
 
(Status of project as of May 2007)

Implementing Country: Botswana

Developers:
Botswana Ministry of Education
BOTUSA Project
World Health Organization
Education Development Center, MA

Date Started: July 2006

Theory or Formative-based:
 Needs assessment conducted
 Based on best practices in school-based curricula from literature
 Extensive pilot testing of draft materials
 Ministry completed baseline survey for future evaluation purposes

For more information contact:
Lydia Seeletso
Email: SeeletsoL@bw.cdc.gov
Program type: School curricula

Focus:
 Healthy decision-making and sexuality
 Communication/negotiation skills
 ABC
 Social and personal responsibility

Target Population:
School age youth (Separate curricula for youth age 6-7, 8-9, 10-12, 13-16, 17-18)

Venue:
Primary and secondary schools

Materials:
 Teacher guides
 Student workbooks
 Teacher training resource packet

Program Description:
The Skills for Life: Botswana’s Window of Hope curriculum has been developed for use in all grades (standards 1-2, 3-4, 5-7, junior secondary school, and senior secondary school). The curriculum is not intended to be an add-on during the school day, but rather the lessons and activities are infused and integrated across as many subject areas as possible. The materials help teachers discuss life issues important to youth, including self-awareness, goal setting, stress management, social responsibility, health living, relationships, sexuality, risk reduction, and facts and myths about HIV/AIDS. Teachers use stories, role-playing, poems, class discussions, and other interactive means to impart knowledge and build skills for health decision-making. The materials discuss HIV prevention, promote abstinence and delay sexual debut; for students ages 15 and older, the program also brings up the issue of cross-generational sex, and provides referrals for condoms and other prevention interventions.

(Status of project as of June 2007)

Implementing Country: Malawi 

Developers:
USAID, JHU Center for Communication Programs (BRIDGE Project)

Date Started: April 2006

Theory or Formative-based:
 Based on formative research conducted by the BRIDGE project showing that Malawians have high knowledge and awareness of the “ABC” messages, but feel little control over their lives, do not believe there is anything they can do to prevent HIV infection, and have low perceived personal risk
 Initial evaluation research conducted April 2007- data being analyzed
 Final evaluation planned for 2008

For more information contact:
Kirsten Böse kbose@malawibridge.org
Program Type: Multimedia campaign

Focus:
 Fidelity in marriage
 Gender roles

Target Population: Married males

Venue: Community-based settings

Components:
 Multi-sectoral mass media campaign
 Community discussions led by trained male religious leaders and other community based groups

Materials:
  Bambo Wachitsanzo certificate
 Activities package (Hope Kit update)
 Posters & flyers
 Radio spots
 
Glory Mkandawire
gmkandawire@malawibridge.org

Program Description:
Bambo Wachitsanzo is a multi-media campaign that builds on the success of the first phase of the Nditha! (“I can do it”!) campaign.  It combines nationwide media coverage (radio spots and posters) with community outreach to underscore the message that Malawian men can take responsibility in their families and community to prevent the spread of HIV/AIDS.  The objective of the campaign is to encourage Malawian men to take responsibility for and invest in their families by promoting mutual faithfulness to prevent HIV. The campaign promotes introspection regarding traditional gender roles and highlights small do-able actions that men can take to help them demonstrate their involvement in their families and communities, and promote adoption and adherence to mutual faithfulness to help prevent HIV/AIDS. Men who commit to faithfulness are recognized as Bambo Wachitsanzo, terrific guys who are respected in their homes and community.

Core Elements:
 Mass media campaign as a foundation for the activities
 Community outreach activities
 Bambo Wachitsanzo clubs
 Caravan for Life (FBO activity)
 Bambo Wachitsanzo activity package used by community groups to promote discussion around gender norm and social roles to promote men’s involvement
 Certificates awarded to men who are Bambo Wachitsanzo.
 
(Status of project as of June 2007)

Implementing Country: Mozambique

Developers:
Peace Corps/Mozambique

Date Started: April 2006

Promising Idea:
 Project strategy and materials draw upon several other organizations' research and program design for male-focused behavior change
 Currently conducting an internal evaluation (complete by Jan. 2008)

For more information contact:
Bern Moorehead
Email: coord-central@joma.pcmoz.org

Program Type:
Peer education and life skills

Focus:
 Gender norms, esp. masculinity
 Choosing healthy behaviors to prevent HIV

Target Population:
 Males 14-17
 Secondary school teachers

Venue: Secondary schools

Components:
 Annual conference
 Micro-projects in secondary school clubs
 Training for teachers

Materials:
 Peace Corps: Life Skills Manual
 CEDPA: Choose a Future!
 SAT Regional: Mainstreaming Gender in HIV and AIDS Work

Program Description:
The purpose of the JOMA Project is to work with young men to explore Mozambican concepts of gender, in particular masculinity, with the ultimate goal of reducing HIV incidence among youth in secondary school. Young men learn to critique Mozambican norms for masculinity and the behaviors that follow these norms.  The project is led by Peace Corps Volunteers (PCVs) and Mozambican teachers working in secondary schools. PCVs conduct trainings with their Mozambican colleagues to develop the teachers’ self-perceptions as role models (“heroes for healthy behavior”) and teach the technical skills to plan and facilitate youth-led peer education projects. During an annual conference, teachers and students are introduced to the concepts of gender and explore gender roles in the context of HIV/AIDS, while developing communications skills with the guidance of professional journalism, photojournalism, theatre and art trainers. Students and teachers return to school and plan, budget, and carry out communication micro-projects while continuing to examine gender norms and select healthier behaviors. JOMA clubs meet with young women’s clubs to expand debates and discussions on gender. Students work to overhaul male stereotypes and social norms, while promoting healthier attitudes and practices among their peers through a selected communications medium.
 
Core Elements:
 Work with young men to develop understanding of how cultural norms of masculinity lead to unhealthy behaviors.
 Training of youth in various communications media as part of the process of developing critical thinking and interpersonal communications skills - not simply to "pass on the message."
 Male-focused programming in coordination with female-focused programming. Behavior change in young men cannot be separated from parallel work on women’s empowerment, and vice-versa. This is accomplished in the JOMA project by partnering with young women’s clubs to debate and discuss cultural norms.

Resources:
 JOMA website: http://joma.pcmoz.org/
 2007 Biannual project report:
http://joma.pcmoz.org/files/JOMA_conf07rep_en-US.pdf
 Implementer’s Meeting (Kigali, June 2007) presentation: http://joma.pcmoz.org/files/PeaceCorpsMoz_MensProject_HIM2007.pdf 
 
(Status of project as of May 2007)

Implementing Countries:
South Africa, Kenya
(Other countries have also implemented the MAP program, adapting it to local needs)

Developers:
USAID, Engenderhealth, Planned Parenthood Association of South Africa

Date Started: 1998

Theory or Formative-based:
 Small scale evaluation demonstrated positive changes in workshop participants’ knowledge, attitudes, and practices (Kruger 2003)
 Impact evaluation in progress

For more information contact:
Andrew Levack
Email: alevack@engenderhealth.org

Program Type:
Interpersonal approaches

Focus:
 Male norms
 Gender based violence
 Male involvement in reproductive health, including HIV prevention

Target Population:
Older male youth and adult men

Venue:
Community-based settings (workplaces, trade unions, prisons, military bases, FBOs, community halls, youth clubs)

Components:
 Educational workshops
 Community education and mobilization

Program Description:
The central foundation of the MAP program has been the implementation of workshops with men and mixed-sex groups that explore gender roles and promote gender equality. The program challenges contemporary gender roles that equate manliness with a range of risky behaviors such as violence, alcohol use, pursuit of multiple sex partners, and domination over women. The program has expanded to also include mobilizing men to take action in their communities through Community Action Teams, media and political advocacy in changing social norms, and collaboration with grassroots organizations to encourage positive male involvement in reproductive health, including HIV prevention.

Resources:
 Brief: http://www.engenderhealth.org/ia/wwm/pdf/map-sa.pdf
 Kruger, V. (2003) MAP evaluation report. Johannesburg: EngenderHealth.
 
(Status of project as of June 2007)

Implementing Country: South Africa

Developers: Population Council

Date Started: January 2006

Theory or Formative-based:
Prior to implementation:
 Conducted a baseline survey of knowledge about HIV/AIDS and prevention, and FBO involvement in HIV prevention
 Held a consultative meeting with Faith Based Leaders on program feasibility
 Pilot tested curriculum
 Conducted a survey on the acceptability, success, and impact of the pilot

For more information contact:
Nathi Sohaba
Email: nsohaba@popcouncil.org
Program Type: Multi-faceted communications program

Focus:
 Mutual monogamy

Target Population:
 Congregation members
 Church couples

Venue: Churches

Components:
 Training of church leaders
 Workshops
 IEC
 Peer counseling
 Service referrals
 Community outreach

Materials:
  Curriculum 

Program Description:
The purpose of this program is to build FBO capacity to deliver mutual monogamy interventions to church members. Church leaders and peer counselors are trained to implement the program strategies (workshops, sermons, information materials, peer counseling, and referrals to services) in order to increase church members’ knowledge about HIV, acceptance of mutual monogamy, and to reduce the number of sex partners and increase HIV testing among church members, particularly couples.

Core Elements:
  Couples workshops that provide information and skills to church couples/partners on HIV risk reduction and achieving and maintaining mutual monogamy in relationships
 Congregation-wide messages that increase general knowledge of HIV, create greater acceptance of mutual monogamy as a social norm, and promote HIV testing
  Information materials that build general awareness and support for mutual monogamy among congregation members
 Counseling that provides support and resources to couples and other church members on issues related to HIV, mutual monogamy, and other social and family matters
 Referral network that increases access for couples and other church members to needed social, medical, and mental health services
 
(Status of project as of June 2007)

Implementing Country: Swaziland

Developers:
USAID, NERCHA

Date Started: July 2006

Theory or Formative-based:
Surveys showed (Halperin, 2006):
 86% of Swazis surveyed had heard of the campaign
 78% said that the campaign made them consider changing their own sex behavior
 1 year after the campaign, the % of adults reporting 2 or more partners in the last 4 weeks had fallen by half

For more information contact:
Sibusiso Mngadi
Email: smngadi@nercha.org.sz

Program Type: Multi-media campaign

Focus:
 Faithfulness to one partner

Target Population:
 Young singles
 Married couples

Venue: Nationwide

Components:
 Media campaign (radio talk show, newspaper, TV and billboard ads)
 Interpersonal communication (community-based dialogues for men)

Materials:
 Posters
 Brochures

Program Description:
This campaign included a radio talk-show, newspaper, radio, and TV ads, including billboard messages about the devastating effects of unfaithfulness (Makhwapheni uyabulala—your secret lover can kill you). The campaign, with its explicit messages, was highly controversial, although appeared to be effective in raising awareness around the risks of multiple, concurrent partnerships. In response to the controversy, the campaign has adopted positive messaging involving partners who have reformed from the practice of casual sex.

Core Elements:
 Advertising campaign
 Interactive radio talk show
 Community-based dialogues targeting men
 Buy-in from media to gain their support of the campaign strategy

Resources:
 Halperin D, Andersson N, Mavuso M, Bicego G. Assessing a national HIV behavior change campaign focusing on multiple concurrent partnerships in Swaziland.  International AIDS Conference Oral Presentation Abstract: Toronto, August 2006.
 
(Status of project as of May 2007)

Implementing Country: Haiti

Developers:
Department of Labor (USA), Academy for Educational Development, Behavior Change Communication Technical Working Group, SMARTWork

Date Started: FY07

Promising Idea

For more information contact:
Whitney Warren
Email: warrenw@ht.cdc.gov

Program Type: Multi-channel communications campaign

Focus:
 Condom use
 Partner reduction
 Fidelity to one partner

Target Population: Adult men

Venue: Male-dominated workplaces

Components:
 Workshops
 Outreach
 Special events
 IEC materials 

Program Description:
The “manly man” strategy targets male workforce populations and works to build upon positive aspects of male identity, combining these with behavior change messages. The campaign emphasizes that “manly men” consistently use condoms, reduce the number of sex partners, and preferably are faithful to one partner.
(Status of project as of May 2007)

Implementing Country: Haiti

Developers:
CDC, Family Health International

Date Started: FY05

Promising Idea

For more information contact:
Whitney Warren
Email: warrenw@ht.cdc.gov

Program Type: Awareness raising and peer education

Focus:
 Fidelity/Partner reduction
 Condom use
 Promotion of VCT

Target Population:
Uniformed services (police, customs and immigration officers)

Venue: Police headquarters and customs and immigrant departments

Components:
 Advocacy
 Training
 Peer education 

Program Description:
This project is aimed at preventing HIV and STI transmission among the uniformed services. The activities include: 1) awareness raising meetings at headquarters of each department, with message delivered about HIV/AIDS transmission, prevention, VCT, human rights, and anti-stigma policies; 2) adaptation of the basic training curriculum for the national police academy to incorporate HIV prevention; and 3) a peer education program to train service men to conduct outreach to peers with messages to promote condom use, partner reduction, and VCT.

Core Elements:
  Training of police officers as peer educators
  Motivation and sensitization of police officers
  Strong collaboration between police headquarters and implementing agency
 Logistical support from the health unit of the uniformed services/peacekeeping force 

Section 2

Program Models to Address
Cross-Generational/Informal Transactional Sex
 
(Status of project as of May 2007)

Implementing Country: Kenya

Developers:
 Centers for Disease Control and Prevention
 Institute of Tropical Medicine
 Kenya Medical Research Institute
 Innovative Program Solutions

Date Started: 2006

Evidence-based:
Adapted from a US-based best-evidence intervention (Jemmott et al, 1998)

For more information contact:
Hilda Vandenhoudt
Email: Hvandenhoudt@ke.cdc.gov
Chris Obongo
Email: Cobongo@ke.cdc.gov

Program Type: Participatory education

Focus:
 Abstinence
 Condom use
 Avoidance of risky situations:
peer pressure, transactional sex, cross-generational sex

Target Population:
Youth 10-14
Youth 13-17 (separate curricula)

Venue: Community-based settings

Components:
 Small-group workshops with interactive skill-building activities

Materials:
 Curriculum/participant handouts
 Training materials

Program Description:
This program focuses on knowledge, attitudes, and prevention skills related to HIV, STIs, and pregnancy.  It also focuses on relationship issues, perception of risk, sexual behavior, decision-making and negotiation in difficult situations.  It provides specific information on ways to reduce risk by practicing safe sex (abstinence, condom use, communication with family members and friends)  and provides skills to avoid risky behavior and circumstances (cross-generational and transactional sex, funeral discos*) in the context of healthy choices for a better future, making a difference, and being responsible.

* Funeral disco (or disco matanga) is a Kenyan tradition of playing disco at during the funeral to fundraise for the bereaved family. It is an event where many young people experience their first sex and substance use (alcohol and soft drugs such as marijuana). Parental monitoring is lacking.
 
Core Elements:
 Use interactive, small group sessions
 Identify what it means to make healthy choices for a better future, to make a difference, to be safe and how to achieve these goals
 Identify behaviors/circumstances that put youth at risk for HIV/STIs and pregnancy
 Teach that being safe means: abstaining from sex, using condoms every time you have sex, avoiding risky situations, talking with friends and family members about one’s choices, knowing your HIV status and that of your partner
 Develop perceived vulnerability and understanding of consequences of HIV, STIs, and pregnancy
 Enhance participants’ sense of and responsibility in negotiating safe sex
 Build communication and negotiation skills regarding abstinence or use of condoms
 Build skills to resist situations that place youth at risk

Resources:
 Jemmott JB, Jemmott LS, Fong GT. Abstinence and safer sex HIV risk-reduction interventions for African American adolescents. JAMA. 1998; 279(19): 1529-36. 
(Status of project as of June 2007)

Implementing Country: Cameroon

Developers:
Population Services International,
Cameroon Social Marketing Association (ACMS), Gesellschaft fur Technishce Zusammenarbeit (GTZ), West African Ambassador Fund, AWARE-HIV (Accra)

Date Started: June 2005

Theory or Formative-based:
An evaluation conducted on an earlier phase of this campaign (focused on the cross generational sex phenomenon in urban areas) showed cross-generational sex is an accepted and common practice in Cameroon.  Risk perceptions are low, and in some regions, traditional norms and religious beliefs tends to favor sexual relations between pre-adolescent girls and older men. (Ndonko et al., 2005)

For more information contact:
Heyndricks N. Bile
Email : heyndricksn@yahoo.fr
Program Type:
Mass media and interpersonal campaign

Focus:
 Abstinence, Be faithful
 Cross-generational sex

Target Population:
 Young girls (15-24)
 Men above age 30
 Religious and traditional leaders
 Parents

Venue: Community-wide

Components:
 Mass media (TV, radio, print)
 Youth forum
 Advocacy workshops

Materials:
 Posters
 Radio & TV spots
 Leaflets

Program Description:
The “No to Sugar Daddies, No to AIDS” campaign aims to break the silence and raise public awareness of the dangers involved and change social views around cross-generational sex. The campaign focuses on two themes: 1) to raise awareness about the dangers and consequences of cross-generational sex and 2) to promote healthy sexual practices among adults and youth affected by this phenomenon. The goal of the campaign is not only to reduce the transmission rates of HIV from older men to young girls, but also to promote girls’ empowerment by encouraging girls to stay in school and develop long-term strategies for a healthy and productive lifestyle.  By facilitating open and frank discussions about sexual activity between community leaders, parents and youth, this program helps communities identify and respond to situations where power is used to extract sex from young girls, thereby exposing them to unwanted pregnancy, emotional trauma and HIV/AIDS.

Resources:
 Ndonko F,  Gruber-Tapsoba T, Bile H & Foyet L. Argent, sexe et mensonges : étude sur la sexualité transgénérationnelle au Cameroun. 2005. 

(Status of project as of May 2007)

Implementing Countries:
Kenya, Uganda, Tanzania

Developers:
USAID, IMPACT, PATH

Date Implemented: 1999-2006

Theory or Formative-based:
 Conducted an in-depth formative assessment of the community prior to program development
 Creative workshops with key stakeholders also contributed to development of the communication strategy
 An independent study (2003) indicated that the radio show was widely heard by youth and adults
Program Type: Multi-channel communications campaign

Focus:
 Teens’ decision-making surrounding sexual activity, drugs and alcohol, relationships, and HIV/AIDS

Target Population: Youth

Venue: Community-wide

Components:
 Radio drama series
 Comic books

Materials:
  Comics
 Tape recordings of radio drama 

For more information contact:

John Waimiri
Email: jwaimiri@path.org

Program Description:
The goal of this project was to reduce HIV transmission risk by stimulating community dialogue on risk settings and causes of high-risk behavior through delivery of a consistent, linked message from a variety of channels. The project communication strategy, “Question Your Relationships” was mirrored through the communication activities, including a radio drama series (Kati Yetu, or “Between Us”) and a comic book series. Both the radio drama and comics star Nuru—an African teenager who, along with her friends, confronts many problems faced by African youth including cross-generational sex, rape, pregnancy, and HIV/AIDS. Interlocking plots and cliffhangers draw listeners in and give them a chance to think and talk about the issues presented.

The radio program consisted of a 15-minute soap opera and a 15-minute segment with a moderated discussion. Radio groups, or peer facilitation groups, were also established; these groups listened to an episode and then discussed issues raised during the show. These discussions were used to plan subsequent radio programs. The Kati Yetu cassette tapes are available for other groups to use for their own health education programs.

The youth-oriented comic book series was designed to foster positive attitudes and perspectives that will help youth consider quality relationships and make safe sexual behavior choices. It was intended as a vehicle to provoke lively, informal discussions among young people.
 
(Status of project as of May 2007)

Implementing Country: Uganda

Developers:
USAID, JHU Health Communication Partnership, Young Empowered and Healthy (YEAH) Initiative, Uganda AIDS Commission

Date Started:
Material development began in 2003

Theory or Formative-based:
 Workshops with young people in which they identified their own vulnerabilities and agreed that “sexual exploitation” was a key issue they wanted the campaign to address
 Some qualitative research on “sugar daddies”

For more information contact:
Sereen Thaddeus
Email: SThaddeus@usaid.gov

Program Type: Multi-media campaign

Focus:
 Transactional and cross-generational sex

Target Population:
Youth 15-24

Venue: Community-based settings (schools, sports clubs, faith based groups, youth clubs)

Components:
 Radio serial drama
 Journalism contests
 Interactive DVD
 Reinforcing materials
 Road shows

Materials:
 Radio spots
 Supporting materials (comic books, posters, billboards, exercise books, board game)
 Community Guide for Community Action against S4SL
 Training materials
 Listening Guide and recordings of serial drama
 
Program Description:
The centerpiece of this program is a radio serial drama, Rock Point 256, in which characters model positive behavior change over time. The series concentrates on transactional sex and gives young people three clear messages: abstain until you are ready for a long-term relationship, set long term goals that you do not compromise for material gain, and do not give or receive gifts or favors in exchange for sex. Adults are given the message: examine your personal role in protecting young people. The overall message is that Something for Something Love is a short term gain but results in long-term loss.  The program also includes journalism and school contests aimed at stimulating community dialogue about transactional sex. Supportive media materials reinforce Something for Something Love messages in a variety of community-based settings and through various media. 

Core Elements:
 Youth initiated and implemented campaign
 Stimulate discussion about common yet taboo topic
 Highlight gender norms that underlie S4SL
 
(Status of project as of June 2007)

Implementing Country: Uganda

Developers:
2004 – 2005 pilot: USAID, Population Services International, AIDSMark
2007-2009 follow-on: USAID, YouthAIDS

Date Started:
Pilot: Sept. 2004 – Sept. 2005
Follow-on program: Jan. 2007 – Jan. 2009

Theory or Formative-based:
 Based on qualitative research which revealed the motivations for cross-generational sex and a low risk-perception for the practice (AIDSMark 2004)
 Follow-up surveys show that levels of cross-generational sex among females in the program did not change significantly, but among females not in the program, these relationships increased by 19%
 Young women in the program were more likely to reject cross-generational sex as an acceptable social norm, have higher confidence to refuse sex with older men, and recognize the risks associated with such relationships
 Baseline research for the follow-on is on-going (PSI Uganda Cross Gen University Baseline TRaC, 2007)
Program Type:
Peer education and life skills

Focus:
 Young women’s empowerment (life skills, confidence building, long-term goal setting)
 Awareness of HIV risk associated with cross-generational sex
 HIV Counseling and Testing

Target Population:
 Young university women
 Girls in secondary school (13-18yrs)

Venue:
Universities and secondary schools

Components:
 Peer education through small group discussions and special events
 Role model presentations
 Coordination with the private sector to organize summer internships
 Mass media campaign
 Free HIV Counseling and Testing

Materials:
  Peer educator training curriculum and support materials
  Print materials (posters, brochures, advocacy guides)
 Radio spots
 TV Ads

For more information contact:

Twebese Rukandema
Email: trukandema@psiu.co.ug

Program Description:
PSI/Uganda created Go Getters clubs as part of a pilot program to decrease cross-generational sex in Uganda. The overall program uses a variety of interlinked approaches to highlight the risks of cross-generational sex and emphasize the benefits of safer sexual practices at individual, family, and community levels. In January 2007, PSI Uganda received additional funding from YouthAIDS to scale up the program. The program now includes 10 Universities nationwide and 50 secondary schools in 5 districts. The main strategies of the program include: outreach to female students to build their confidence and skills (Go Getters project); a radio and print campaign to communicate key messages about cross-generational sex; advocacy by political and religious leaders to socially denounce the practice; and parent skills training to increase parent-child communication about reproductive risks. Free HIV Counseling and Testing has now been added as an additional component in the universities program in response to data that showed that only 15% of women aged 20-24 have ever tested for HIV

For the Go Getters project, peer educators from the participating schools and universities are trained to work with their peers to impart life skills, raise awareness of HIV risk, cultivate confidence, and encourage young women to look beyond short-term gratification and set long-term goals. Also, since providing job skills and employment opportunities gives tangible alternatives to cross-generational sex, PSI has worked with the private sector to secure internships and other opportunities for Go Getters members in the university program.

Core Elements:
 Peer education
 Internships
 Mass media and IEC campaign
 Role model presentations
 Advocacy
 Baseline and follow-on quantitative surveys
 
(Status of project as of May 2007)

Implementing Country: Zambia
(Delayed Debut campaign implemented in 16 Africa countries)

Developers:
USAID via AIDSmark
Population Services International
Society for Family Health

Date Started: January 2006
(Posters and basic materials have been produced, but full implementation has not been realized due to lack of funds)

Theory or Formative-based:
 Developed from qualitative research in several African countries that identified barriers to teens delaying sexual debut
 Materials pilot-tested in 5 countries
 Interpersonal communications program pilot-tested and found to impact risk perception, self-efficacy to negotiate peer pressure, and acceptability of romantic relationships without sex among youth
 IC program was met with much enthusiasm and successfully enhanced mutual respect between parents and youth and broke down communication barriers
Program Type: Interpersonal approaches and Multimedia campaign

Focus:
 Delayed sexual debut and secondary abstinence
 Risk reduction for sexually active youth
 Parent-adolescent communication about sex
 Gender norms

Target Population:
Adolescents (13-19) and their parents

Venue: Schools, homes, FBOs, churches, and other organizations working with youth

Components:
 Multimedia campaign (TV, radio, print)
 Interpersonal communications program

Materials:
 IEC materials
 Posters
 Facilitator’s guides

For more information contact:
Marta Levitt-Dayal (USAID/Zambia)
Email: mlevittdayal@usaid.gov

Ben Chirwa(National AIDS Council/Zamiba)
Email: bchirwa@nacsec.org.zm
 
Program Description:
The Safe From Harm interpersonal communication program and Delayed Debut media campaign were created based on qualitative research with 14-19 year olds that concluded that sexual violence and coercion, intense peer pressure, and transactional sex are major barriers to delayed sexual debut for African teens. The interpersonal communication program equips parents with the knowledge and skills to increase the amount and quality of in-home sex education and adolescents with communication skills, to support the delay of first sex for non-sexually active youth, and to encourage risk reduction for sexually active youth. The program is complimented by the Delayed Debut mass media campaign, which includes messages on TV, radio, and in print encouraging young people to rethink what it means to be a “real man” or a “real woman,” and promoting adolescents to delay sexual debut or abstain if already sexually active.

(Status of project as of June 2007)

Implementing Country: Zimbabwe

Developers:
National Institute of Child Health & Human Development
Women’s Global Health Imperative

Date Started: February 1, 2006

Theory or Formative-based:
 Based on social and economic empowerment theory
 Conducted qualitative formative research
 Field tested and revised intervention based on pilot results
 Outcome evaluation (using randomized control design) in progress to assess the effect on economic livelihood and sexual behavior and biologic outcomes

For more information contact:
Megan Dunbar
Email: mdunbar@globalhealth.ucsf.edu

Program Type:
Economic and life skills

Focus:
 Economic security, youth development and life-skills
 HIV/reproductive health education
 Gender issues and sexual negotiation skills

Target Population:
Out-of-school female orphans (16-19)

Venue:
 Vocational training centers
 Public youth-friendly clinics

Components:
 Micro-credit program (includes entrepreneurial training, loan provision, practical business education, mentorship, and peer support groups)
 Life-skills education curriculum

Materials:
 SHAZ! life skills curriculum
 Red Cross Zimbabwe home-based care training manual
 SHAZ! “Launch for Life” practical business, budgeting and financial skills training
 

Program Description:
Shaping the Health of Adolescents in Zimbabwe (SHAZ!) is an economic and life-skills intervention aimed at providing alternatives for young girls to help them avoid sexual relationships that transmit HIV, including cross-generational and transactional sex. The ultimate goal of the project is to help out-of-school orphaned females gain control over their sexual interactions and avoid the adverse consequences of unprotected sex. The intervention consists of an economic intervention (combining vocational skills and practical business training with start-up grants and linkages to micro-financial institutions) that supports the girls in developing careers and/or establishing their own small businesses.  The economic intervention is combined with a previously tested life-skills education curriculum that delivers HIV/reproductive health education through the use of role plays, drawing exercises, and other techniques to help participants negotiate gender-power interactions and the terms of their sexual relationships.  Social-support is fostered through peer groups formed during life skills training, self-selected mentors (who are assisted with information and activities), and on site guidance counseling. 

Core Elements :
 Economic skills training (vocational and business training, micro-grants, linkages to micro finance institutions)
 Like skills education (HIV, reproductive health, relationship negotiation, home-based health care training)
 Social support (peer groups, self-selected mentors/guardians, and guidance counselors)