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Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania. Suzanne Maman Health Behavior and Health Education. The associations between HIV and violence. Violence as a risk factor for HIV infection

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Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania

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Skinning the goat and pulling the load hiv risk and violence among youth in tanzania l.jpg

Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania

Suzanne Maman

Health Behavior and Health Education


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The associations between HIV and violence

  • Violence as a risk factor for HIV infection

    • Women in violent relationships less able to enforce HIV preventive behaviors.

    • Women who have experienced physical and sexual abuse engage in more HIV risk behaviors.

    • Biological trauma from forced sex may facilitate HIV transmission.

  • Violence as an outcome of HIV status disclosure

    (4) Violence is a major barrier to disclosure for HIV+ women.


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    Growing evidence of the overlapping epidemics of HIV and violence

    • In South Africa, women with violent partners have a more than 50% increased risk of acquiring HIV. (Dunkle et al., 2004)

    • In Tanzania, the odds of reporting violence are 10 times higher for young, HIV-positive women as compared to young, HIV-negative women. (Maman et al., 2002).


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    Rationale for working with young men

    • Men are generally perpetrators of gender-based violence

    • Men control the terms & conditions of sexual relationships

    • Very little is understood about the attitudes and behaviors of young men in this context

    • Young men lack access to information and services

    • Adolescence is a time when lifelong patterns are formed


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    Tuelemishane ProjectDar es Salaam, Tanzania

    An intervention to reduce HIV risk and reported use of violence among young men using a combination of peer support and community theatre


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    Tanzania

    Population: 33 million

    Pop in Dar: ~ 3million

    Per capita GNP: $246

    Life expectancy: 45 years

    HIV prevalence: 8.8%


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    Intervention Design

    The intervention consists of two major components:

    • Community Theatre

    • Trained theatre group perform interactive skits

    • Performances in venues frequented by young men

    • 3 different skits performed 12 times

    • Peer support

    • Young men enrolled in groups of 10-12

    • Groups meet monthly for 12-months

    • Facilitated by trained peer group leaders


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    Research Design

    • Formative Phase

    • IDI

    • 14 FGD

    Evaluation Design

    Intervention

    475 men, 16-24 yrs

    Interviewed baseline

    Participate in intervention

    Interviewed 2 month

    Post-intervention

    Control

    475 men, 16-24 yrs

    Interviewed baseline

    Interviewed 2-month

    Post intervention

    IDIs with the female partners of 40 men


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    Formative and Baseline Findings


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    Relationships revolve around sexual activity

    • To love a partner means one must be willing to have sex

      • “How can she be my partner without making love? To know that she loves you and she’s your partner you must make love, that’s why I convinced her. “ (male, 24 years, not married)

    • There were few examples of partnerships between young men and women that did not involve sex.


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    Mistrust of sexual partners due to concerns of infidelity

    • Youth described little emotional/romantic love

    • Mistrust stemmed from concerns about infidelity and financial motives

    • Infidelity openly acknowledged by men and some women

    • Infidelity the most common trigger for violence mentioned by women


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    Mistrust also related to the transactional nature of relationships

    • Expectations of money/ gifts from male partners

    • Money/gifts used as yardstick to measure the degree of men’s love.

    • Some women engaged in sexual relationships out of need

      • “When girls need assistance they must have sex to get that assistance.” (male, FGD participant)

    • Concerns over the financial motivations of women was the primary trigger for violence mentioned by men.


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    The language that youth use to describe their relationships reflect the mistrust

    • Pulling the load (Anavuta mzigo)

      • Men describe taking on new girlfriends as pulling the load

    • Skinning the goat (Kuchuna buzi)

      • Women describe strategies to extract money from their partners as skinning the goat


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    Conservative attitudes regarding gender norms and expectations

    • 69% of men agreed that men should have final say in all family matters

    • 48% felt women should tolerate being beaten to keep family together

    • 44% felt if women want to leave abusive partner they must leave children behind


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    Experiences with violence in childhood were common

    • 11% reported unwanted sexual touching or intercourse under the age of 12 years

    • 43% reported experiencing serious physical violence as a child

    • 28% reported witnessing their father physically assault their mother


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    Young men describe substantial HIV risk

    • 70% of men were sexually active and the mean age of first sex was 16 years (SD 2.90 years)

    • The mean number of lifetime partners was 3.96 (SD 5.55)

    • 47% reported having had sex without a condom in the past 6 months


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    Use of physical violence against female partners was high

    • Among sexually active men, 30% reported at least one episode of physical violence with a partner

    • 9% reported using physical violence to force a partner to have sex

    • 5% reported reacting violently when a partner refused to have sex


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    Factors associated with the use of physical violence

    • Number of sexual partners

      • Men with 4-10 lifetime partners had 5 X greater odds of reporting violence (95% CI: 2.6-10.4)

      • Men with 2 or more partners in the past 6-months had 2 X greater odds of reporting violence (95% CI: 1.19-4.56)

    • Pressure from peers to have sex

      • The odds of reporting violence was 2.5 X higher among men who report moderate pressure from peers to have sex (95% CI: 1.30-4.99)

    • Childhood physical abuse

      • The odds of reporting violence was 2 X greater for men who experienced physical violence in childhood (95% CI: 1.42-3.33)


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    Conclusions


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    Despite being two decades into epidemic, youth are still at risk

    • 8.8% of Tanzanians are HIV infected nationally

    • 60% new infections occur among 16-24 yr olds

    • Multiple partnerships were common

    • Unprotected sexual intercourse was common


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    Men control the sexual decision making in relationships

    • Men describe conservative attitudes related to sexual norms and expectations

    • Women have limited agency in the process of initiating and maintaining partnerships


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    The socioeconomic context plays a role in the formation and dynamics of sexual relationships

    • Women engage in sexual relationships to achieve financial support

    • The transactional nature of relationships leave women vulnerable to both HIV risk and violence


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    There were clear associations between HIV and violence

    • Men with more sexual partners report using violence more often

    • Infidelity was the trigger for violence mentioned most often by women


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    Tuelemishane Project

    • Moves us out of the clinic into the community, and shifts the focus from women to men

    • Designed to give men space to talk about norms surrounding sexual behavior and conflict.

    • Through a 1-year intervention we hope to see some changes in attitudes and norms—and optimistically behaviors.


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    Where do we go from here?

    • One approach is not sufficient

      • Multi-level interventions are needed

    • The challenge is to reach men where they spend time & to keep them engaged

      • Venue-based interventions

    • Younger men need to be the focus of our interventions


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    Acknowledgements

    Funding: The intervention is funded through a grant from USAID, Interagency Gender working group. The research is funded by The Population Council Horizons Project.

    Co-Investigators

    J. Mbwambo, (Muhimbili); M. Sweat, H.Lary (JHU), M. Roche (UNC); F. Kouyoumdjian (Toronto)

    Research Staff: R. Kaballa, A. Mwampashi, L. Sabuni, E. Kakwezi, U. Peter, L. Ezekiel, E. Chezi, H. Marijani and J. Donath.


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