HIV Prevention Knowledge Base
Behavioral Interventions: Transactional and Age-disparate Sex in Hyperendemic Countries
Adapting a Multi-Faceted U.S. HIV Prevention Education Program for Girls in Ghana
This paper reports on a short-term evaluation of an HIV educational program designed to address sociocultural risk factors among adolescent girls (aged 10–17 years) in sub-Saharan Africa. The program, adapted from a U.S.-based program called “Making Proud Choices,” combined skills training to encourage participants to consider alternatives to TS for financial support and an interactive computer-based program about the risks of age-disparate sexual relationships. The post-test showed significant improvements in HIV-related knowledge and self-efficacy to address HIV and sex in relationships with boys and men. Nevertheless, many still reported that a sugar daddy could give a girl what she needed. The authors note, “It is not surprising that this attitude persisted because the financial and social drivers of these relationships have not been changed.”
Researching and Designing Interventions in a Slum: Using Female Out-of-school Youth as Researchers in Nigeria
Out-of-school female youth is a difficult-to-reach target population in HIV prevention interventions. This program involved working with 36 out-of-school female youth as researchers, then using the research results in the design and implementation of an HIV project. It was found that young women shared more information with the peer researchers than they would outsiders. Community-wide events for parents were also implemented such as theater performances and house visits. Some young women reported that their parents encouraged them to engage in IG sex. The study also found that female-targeted activities would have more impact on this target group than joint male/female youth programs. Involving out-of-school female youth throughout the research and program design process and involving parents in activities to reduce TS are the good practices demonstrated by this project.
Introduction: Addressing the Vulnerability of Young Women and Girls to Stop the HIV Epidemic in Southern Africa
Despite emerging evidence of declining HIV prevalence in countries such as Uganda, the levels of infection and vulnerability among young women aged 15 to 19 years in countries such as South Africa and Botswana remain unchanged, pointing to a continuing failure of HIV prevention efforts in this age group. It is crucial that proven interventions such as delayed sexual debut; reduced numbers of sexual partners, particularly concurrent partners; reduced age-disparate sex; increased condom use; increased male circumcision; and greater access and use of HIV counseling and testing services be implemented concurrently and scaled up to national coverage levels. Fully engaged and committed leadership at the local and national level is needed in order to implement these activities concurrently. These activities must be guided by strategies and processes defined by local communities to address their specific contexts and the existing gaps from the state to individual levels.
HIV Prevention for Young People through the Education Sector in Zambia
HIV incidence among youth in Zambia does not seem to be decreasing, and female youth are more likely to be infected than boys. Higher-risk behaviors such as IG sex, TS, and multiple concurrent partnerships are normalized. The education sector is attempting to address these behaviors through an in-school intervention called CHANGES2, which targets primary school students and addresses barriers to safer sexual behaviors at both the individual and community levels. School-community partnerships are formed to identify and analyze local risk factors. Some risk factors that were identified included student-teacher sexual relationships, gender roles that support men in having multiple partners, and lack of economic opportunities for girls. Data showed that including these partnerships into the program has had a significant positive effect on attitudes toward more equality in gender relations and a decreased tolerance for gender-based violence.
Engaging Men and Boys in Changing Gender-based Inequity in Health: Evidence from Programme Interventions
Research with men and boys shows how inequitable gender norms influence how men interact with their partners, families, and children on a wide range of issues, including preventing HIV and sexually transmitted infection transmission, contraceptive use, and physical violence against women and between men. This review assessed the effectiveness of programs engaging men and boys in achieving gender equality and equity in health, highlighting successful program characteristics. It found that well-designed programs did lead to changes in attitudes and behavior. Programs considered “gender transformative” had a higher rate of change than did the other types of programs. Furthermore, integrated programs were more effective in producing behavior change. Behavior change occurred in all program areas and in all types of programs, but relatively few programs involving men took place over the long-term.
Addressing Cross-Generational Sex: A Desk Review of Research and Programs
This extensive review of IG sex examines the range of programmatic approaches available to prevent or reduce IG sex. The review uses the “continuum of volition” framework used by Save the Children to explore the drivers of IG and TS. The framework assumes that not all young people are vulnerable and/or passive in entering cross-generational sexual relationships. Some empowered youth choose to engage in relationships for “security gains” (emotional or economic). Further along the continuum, “economically rational sex” ranges from sex for “desired material benefits” to sex for survival. At the other end of the continuum are coerced sex and sexual violence, where young women and boys are forced to participate. This end represents power asymmetries and lack of regard for women’s and girls’ health and well-being. The review looks at the approaches used by existing programs to address IG and TS such as 1) creating youth livelihood opportunities; 2) mobilizing and empowering youth to adopt healthy lifestyles; 3) social advocacy; 4) social marketing and “edutainment”; 5) health education and youth rights; 6) addressing power asymmetries, inequity, and poverty; and 7) addressing social and gender norms, including working with men. Despite a gap in concrete evidence on how to reduce TS and IG sexual relationships, the review includes 10 recommendations programs can incorporate into their activities and strategies to reduce TS and IG sexual relations.
Evaluation of Stepping Stones: A Gender Transformative HIV Prevention Intervention
This brief describes Stepping Stones, an HIV prevention project that focuses on developing more gender-equitable relationships. Data from project efforts on the Eastern Cape of South Africa found decreases in HIV and herpes infections among men and women participating in the project, although decreases were not statistically significant. While TS behaviors generally remained unchanged, men participating in the project reported a statistically significant decrease in sex partners at one and two years of follow-up. Qualitative research indicates that profound changes in communication took place among partners, particularly among men and how they related to others. Changes in individual attitudes as a result of the project intervention can ultimately affect HIV rates through providing participants with knowledge about HIV risks, raising awareness of personal risks, and fostering a culture of openness about HIV in the intervention communities.
Cross-Generational Relationships: Using a “Continuum of Volition” in HIV Prevention Work among Young People
The drivers of IG and TS relationships occur along a “continuum of volition.” This continuum suggests that not all young people are vulnerable and/or passive when involved in sexual relationships with persons who are older or more powerful. Rather, there are empowered youth who choose to engage in sexual relationships with older people for emotional reasons; young people who engage in “economically rational sex” for material things such as clothes or passing grades; and youth involuntarily coerced into sex. This paper reviews the use of a program planning tool to locate individual adolescent girls along the continuum and develop appropriate strategies to resist unwelcomed propositions from men in Malawi. The authors suggest that more reflection is needed on why IG and TS are defined as problematic and what aspects are of concern given that IG relationships occur all over the world. When defining TS and IG relationships as problematic, it is important to understand the choices, or lack thereof, that young women have and to address concerns of inequality within the socioeconomic context in which they occur.