O Icheke National Campaign Plan - CONCURRENT SEXUAL ...

Republic of BotswanaNational Campaign PlanMultiple Concurrent PartnershipsMarch 2009

National Campaign Plan: Multiple Concurrent PartnershipsiFOREWORDThe challenge before us is clear. We have made considerable strides towards improving access to care andtreatment for people living with HIV and AIDS, and have dramatically expanded services to prevent motherto-childtransmission of HIV and to test Batswana for HIV. But, as The Mid-term Review of the BotswanaNational Strategic Framework for HIV/AIDS 2003-2009 makes clear, HIV is still spreading across Botswana toorapidly. We need to do more to prevent the transmission of HIV.In light of that, the Government of Botswana has made a commitment to achieving the goal of Zero NewInfections by 2016. This will not be easy and will require a coordinated response from Government,civil society and the private sector. To orient all of the key stakeholders towards a common set of objectivesand activities, we have developed the National Operational Plan for Scaling Up HIV Prevention in Botswana (2008-2010). This document translates our vision into an aggressive prevention programme, one that will fill thecurrent gaps in HIV prevention and intensify, unify and scale up the prevention response.To this end, the National Prevention Operational Plan calls for a high-profile, national, multi-year campaignthat targets the acknowledged drivers of the HIV epidemic. We need such an effort to bring together all ofthe partners, to get us all to pull in the same direction. As we looked at the evidence base to determine ourpriorities, it was clear to us that the initial focus of this campaign should be multiple concurrent partnerships(MCP). MCP is not an easy topic: it will require us to talk about deeply entrenched cultural values and norms,relationships between the genders and other challenging issues. But, as we and other countries in southernAfrica have increasingly realized, this has been a missing piece of our national response.This campaign will play an important role in preventing new HIV infections – by raising awareness about MCPand HIV risk, by encouraging communities, peers, families, couples and individuals to debate and reflect onrisks and values, and by showing those at risk the benefits of changing behaviour and de-stigmatizing HIV. Thecampaign will empower individuals, not only with life-saving knowledge, skills and abilities, but also with theconfidence and motivation to initiate and sustain changes in their lives.On behalf of the National AIDS Coordinating Agency, I would like to thank all those individuals and institutionswho contributed their time and expertise to the development of this national campaign plan. I would like toextend particular recognition to the African Comprehensive HIV/AIDS Partnership (ACHAP), which financedthe development of the campaign plan, and Population Services International (PSI) which spearheaded thedevelopment of the plan. This has truly been an intensive, collaborative, multi-stakeholder, multi-sectoraleffort, and we need to sustain this spirit of collaboration as we roll out the campaign._____________B. C. MolomoNational CoordinatorNational AIDS Coordinating Agency

National Campaign Plan: Multiple Concurrent PartnershipsiiEXECUTIVE SUMMARYThe practice of having two or more sexual partners over the same period of time – multiple concurrentpartnerships, or MCP – is recognised as a key driver of HIV transmission in Botswana. The “NationalOperational Plan for Scaling Up HIV Prevention in Botswana, 2008-2010” calls for Botswana to embark ona high-profile, national, multi-year behaviour change campaign, with MCP identified as the initial focus for thecampaign. This document presents a nationally-agreed plan for implementing the campaign, with commonobjectives, strategies and approaches.This plan is the product of an intensive, multi-sectoral process, involving national- and district-level policymakers,managers and implementers from across the public sector and civil society, all under the guidance ofthe National HIV Prevention Technical Advisory Committee.The campaign was informed by detailed primary and secondary research into MCP. Quantitative and qualitativefindings relating to the nature and extent of MCP and the factors that drive MCP are presented in theannexes to this plan, and a key informant interview report is available on request. One of the most importantinsights from the research is that MCP is not a single phenomenon but a complex and multi-faceted onedriven by a combination of factors, both traditional and modern. Treating MCP as a uniform, monolithic behaviourobscures the variety of motivations that prompt individuals to have partners in addition to their primaryones, and the functions that these additional relationships fulfil. This leads to targeted behaviour change communicationsthat fail to adequately address the needs and motivations of different target groups. A typologythat characterises the different forms that MCP takes is presented in the plan, and this understanding of thecomplexity of the phenomenon underpins the approach taken in the campaign.The campaign will address MCP in all its forms, but will have a strategic focus on young women and adultmen. Messages will address the key factors, some similar, some very different, that drive and motivate youngwomen and adult men to engage in MCP. These include lack of knowledge about concurrency and HIV riskand related calculations that individuals make about the costs and benefits of having concurrent partners; consumerism;and gender, relationship, and peer-to-peer norms and values about sex and relationships. Anotherpriority for the campaign will be the problem of inter-generational sex involving old men who use their statusto have sex with vulnerable young girls, who feel pressured to consent.The campaign will combine approaches that create individual desire to adopt and maintain safe behavioursand those that create enabling environments for sustained behaviour change. Consumer-centred messagingwill be developed to promote the relevant benefits of behaviour change and to shift the values and normsthat shape target groups’ lives so that they feel supported to avoid having multiple concurrent partnershipsrather than encouraged to do so. Throughout, messages will be developed with a view to the cultural dimensionsof MCP.These messages will be disseminated through channels that prompt reflection, catalyze discussion and debate,role-play alternative behaviours and values, leverage supportive cultural norms and encourage those at risk toidentify ways to overcome barriers to change. This will happen through a combination of standalone messaging(which will take a variety of forms, ranging from one-on-one discussions in communities and settings suchas schools and churches to community theatre to radio and television spots) and the integration of MCPmessages into existing HIV/AIDS and sexual and reproductive health activities (from HIV counselling andtesting to support for adherence to antiretroviral therapy to life skills discussions with youth). Institutions andprogrammes that reach different populations who are at risk because of MCP will be assisted to mainstream

National Campaign Plan: Multiple Concurrent PartnershipsiiiMCP messages and adapt communications materials, enabling the campaign to reach youth and adults, malesand females, rural and urban populations, poorer and more affluent people.From the outset, there will be a focus on engaging leaders at national and community level and sensitizingand supporting partner institutions. Sensitization and advocacy efforts will be spearheaded by a team of‘MCP Ambassadors’, acceptable, credible opinion leaders who can engage key individuals and institutions inthe campaign to reduce MCP.The campaign will be characterised by a strong visual identity and a consistent central message, but specificmessages for different target audiences will evolve as the campaign progresses, to maintain interest andprovide solutions to the needs and challenges target groups face as they gain awareness, reflect and attemptto change and maintain behaviour.The campaign will be led and coordinated by NACA through a dedicated campaign unit, supported by a leadtechnical agency (PSI). Rollout of the campaign at district level will work through Ministry of Local Governmentstructures including District AIDS Coordinating Offices and District Multi-Sectoral AIDS Committees.

National Campaign Plan Multiple Concurrent PartnershipsivTable of Contents1 INTRODUCTION: PURPOSE AND PROCESS...................................................... 12 BACKGROUND: MULTIPLE CONCURRENT PARTNERSHIPS.......................................... 22.1 Policy Context............................................................................................................................. 22.2 MCP and HIV Risk...................................................................................................................... 22.3 Estimates of MCP........................................................................................................................ 32.4 Underlying Causes of MCP....................................................................................................... 32.5 Can MCP Change?..................................................................................................................... 53 STRATEGIC FOCUS OF THE CAMPAIGN............................................................... 63.1 The Broader Picture................................................................................................................... 63.2 Strategic Priorities: Populations and Behaviours.................................................................. 63.3 Strategic Priorities: Underlying Causes of MCP................................................................... 83.3.1 Young Women Engaged in MCP for Personal or Material Gain.................................... 83.3.2 Men Engaged in MCP for Sexual Variety............................................................................. 93.3.3 Cross-Generational Sexual Partnership............................................................................. 93.4 What Will Success Look Like?................................................................................................. 104 PROMOTING BEHAVIOUR CHANGE........................................................................ 124.1 Approach to Behaviour Change.............................................................................................. 124.2 Campaign Identity....................................................................................................................... 124.3 Reducing MCP among Young Women.................................................................................... 134.4 Reducing MCP among Men...................................................................................................... 134.5 Stages of Behaviour Change and Evolving Messages.......................................................... 145 ROLLING OUT THE CAMPAIGN................................................................................... 165.1 Importance of Leadership......................................................................................................... 165.2 Sensitization................................................................................................................................. 165.3 Management and Coordination.............................................................................................. 175.3.1 National Level......................................................................................................................... 175.3.2 District Level............................................................................................................................ 185.4 Content Development.............................................................................................................. 205.5 Channel Mix................................................................................................................................. 215.5.1 Mainstreaming MCP Messages.............................................................................................. 225.6 Advocacy....................................................................................................................................... 225.7 Schedule for Rollout.................................................................................................................. 236 RESEARCH, MONITORING AND EVALUATION, AND LOGICALFRAMEWORK............................................................................................................................. 256.1 Research....................................................................................................................................... 256.2 Monitoring and Evaluation........................................................................................................ 256.3 Logical Framework..................................................................................................................... 26

National Campaign Plan: Multiple Concurrent PartnershipsvANNEXESAnnex 1: Epidemiological and Policy Context..............................................................................Annex 2. MCP and HIV Risk............................................................................................................Annex 3. Estimates of MCP in Botswana.......................................................................................Annex 4. Who is More Likely to be Engaged in MCP?................................................................Annex 5. Types of MCP.......................................................................................................................Annex 6. Length of Partnerships......................................................................................................Annex 7. Societal Drivers of MCP...................................................................................................Annex 8. Individual Drivers of MCP................................................................................................3033373840444651PARTNERS IN THE DEVELOPMENT OF THE NATIONAL MCPCAMPAIGN PLAN:The following organisations were represented at a National Stakeholders workshop: National AIDSCoordinating Agency (NACA), African Comprehensive HIV/AIDS Partnerships (ACHAP), Botswana/United States of America Project (BOTUSA), Ministries of Health, Education and Skills Development,Labour and Home Affairs, Local Government and Youth, Sports and Culture, Office of the Ombudsman,Radio Botswana, University of Botswana, Botswana National Youth Council, Men Sector (Police, Prisons),Botswana Network of Ethics and Law and HIV/AIDS (BONELA), Botswana Network of People WithAIDS (BONEPWA), Botswana Christian AIDS Intervention Project (BOCAIP), Botswana Couples Forum,Botswana Business Coalition on AIDS, United Nations Children’s Fund (UNICEF), WHO, PathfinderInternational, Makgabaneng, Population Services International (PSI), Johns Hopkins University, Tebelopele,Humana People to People, Family Health International (FHI), Ghanzi Tribal Administration, Ghanzi adolescentsexual and reproductive health clinic, Ghanzi District AIDS Coordinator’s (DAC) Office, True Love Waits,Department of Gender Affairs, Ghanzi Christian AIDS Committee, Kuru Trust, Evangelical Fellowship ofBotswana (EFB), Maun District Multi Sectoral AIDS Committee (DMSAC) and District AIDS Coordinator’sOffice, Botswana Family Welfare Association (BOFWA), Maun Tribal Administration, Botswana Councilof Churches, Love Botswana, Women Against Rape (WAR), Selebi Phikwe District AIDS Coordinator’sOffice, Selebi Phikwe Positive Living Helper Cells (PLHC) Support Group, Ministers Fraternal, SelebiPhikwe Secondary School, Children, Women and HIV/AIDS (community-based organization), BotshabeloCustomary Court, BCL Mine and Central Transport Organization.

National Campaign Plan: Multiple Concurrent Partnerships11. INTRODUCTION: PURPOSE AND PROCESSThe purpose of the national multiple concurrent partnerships (MCP) campaign plan is to fulfil thecommitment under the “National Operational Plan for Scaling Up HIV Prevention in Botswana, 2008-2010”to a high-profile, national, multi-year behaviour change campaign specifically focussing on the acknowledgeddrivers of the epidemic, initially targeting multiple concurrent partnerships.The rationale for a national campaign plan is to create common objectives, messages and resources thatcan be worked towards, communicated and leveraged in a genuinely national and multi-sectoral effort toaddress MCP and thus work towards the Vision 2016 of zero new infections. The campaign will carry thenational HIV prevention branding currently being developed by NACA to demonstrate that it is an integralpart of the country’s broader HIV prevention strategy.The process of developing the campaign plan was, thus, a multi-sectoral one, involving national- and districtlevelpolicy-makers, managers and implementers from across the public sector and civil society. A full list ofthe partners involved in the development of the campaign plan can be found on the previous page.The campaign plan has been developed under the auspices of the National Prevention Technical AdvisoryCommittee (TAC) with funding from the Africa Comprehensive HIV/AIDS Partnership (ACHAP). Theprocess for the campaign plan development was endorsed by the TAC which formed a Sub-Committeeconsisting of NACA, ACHAP, the Ministries of Health, Local Government, Education and Youth, Sports andCulture, BOCAIP, Pathfinder International, PSI, Tebelopele and UNICEF. Other individuals from civil societyand academia were co-opted to provide cultural and target group expertise.PSI was tasked by the Sub-Committee to spearhead a consultative and evidence-based approach to developingthe campaign. PSI conducted a literature and data review and a series of key informant interviews withnational- and district-level stakeholders, in order to build an evidence base for the planning process. Findings(contained in the annexes to this plan) were presented to a diverse group of stakeholders at a NationalStakeholder Workshop. Based on the evidence gathered and stakeholders’ inputs, the Sub Committee thenmet to develop a draft communications strategy, which was presented to the broader group of stakeholders,for further comment and input.After the workshop, the national campaign team refined and finalized the campaign plan and set out themechanisms for operationalizing it, namely a management and coordination plan, workplan, monitoring andevaluation plan and budget. The plan was presented to the National Prevention TAC on 12 August 2008 whounanimously recommended its endorsement as a working document.

National Campaign Plan: Multiple Concurrent Partnerships2. BACKGROUND:MULTIPLE CONCURRENT PARTNERSHIPS22.1 Policy ContextHigh levels of multiple and concurrent sexual partnerships by men and women, with insufficient consistent,correct condom use, and combined with low levels of male circumcision, were identified as the key driversof the HIV epidemic in the southern Africa by an Expert Think Tank Meeting of the Southern African1Development Community (SADC) in May 2006 . The report of this meeting recognized the need to refocusprevention efforts in the sub-region on these key drivers of HIV transmission.In 2007 the Mid Term Review (MTR) of the National Strategic Framework for HIV and AIDS emphasisedthe need to increase prevention efforts in Botswana; in response, the National AIDS Coordinating Agency(NACA) developed the “National Operational Plan for Scaling Up HIV Prevention in Botswana, 2008-2010”2.The Plan outlines intervention methods to achieve significant and measurable progress towards zero newinfections by 2016 and calls for a high-profile BCIC campaign specifically focussing on the acknowledgeddrivers of the epidemic, initially targeting multiple concurrent partnerships. This national campaign plan hasbeen developed in response to this commitment, and is underpinned by the MTR recommendation thatthe behaviour change campaign should focus specifically on young people and on socio-cultural constructsrelated to gender, sex and sexuality, using innovative communication channels.2.2 MCP and HIV RiskMCP describes situations in which an individual has sexual relations with more than one person at the sametime or over the same period of time. MCP contrasts with the pattern of sexual partnerships in which onepartnership ends before another begins and individuals are in only one sexual relationship at the same time;this is commonly described as ‘serial monogamy’.Having concurrent or overlapping partnerships, or partnerships with no break in between, creates highlylinked sexual networks. In the context of high background HIV prevalence, HIV is present throughout theselinked networks, from which few couples are isolated. While self-reported rates of condom use with allpartner types are high, qualitative studies paint a different picture, in which condoms are only used in the firstweeks or months of a new partnership, and then not always correctly or consistently. Risk of transmissionis highest during the acute infection period, which lasts for up to six months after HIV infection, when theviral load is very high. When those newly infected with HIV have more than one partner during the acuteinfection period, the .spread of the virus is facilitated.It is important to draw a distinction between traditional polygamy, practiced within strict cultural parameterswhich actually serve to limit sexual networks to a man and his wives, and the multiple concurrent partnershipsthat are not culturally permitted and which result in the dense sexual networks that characterise today’ssociety.

National Campaign Plan: Multiple Concurrent Partnerships 4are not yet in relationships (but do not want to be without a sexual partner). Additional partnerships forsexual variety may be one-offs, no-strings / just-for-fun casual partners, or relationships with sidekicks, smallhouses or ‘Ma14’. Multiple or additional partnerships for material gain can be for basic survival needs or nonessential,luxury consumer items, and can range from one-offs to relationships such as small house or Ma14.Finally, men and women looking for a serious or stable relationship (i.e., a primary partner) may go through anumber of short-term partners while they are looking.Figure 2-1 Different MCP behavioursMain function of extrarelationshipsAvoidingenforcedabstinenceSexual varietyMaterial gainPotentialprimarypartnerPhysicalseparationOne nightstandsConsumeristwantsPregnancy /childbirthbreakNo-stringspartnersSurvivalsexTypes of MCPTransitionbetweenpartnersSidekicksOne-offsSparewheel[having]Small houses[being]Small housesComing of age[having]Ma 14[being]Ma 14Key informants consulted during campaign development believed that the most frequent type of MCP occursbetween older, wealthier men and younger women motivated by material benefit. Although the phenomenonof ‘sugar mummies’ (older women who seek out younger men) appears to be on the increase, it was stillconsidered much less common than relationships between older men and younger women. A strikingcharacteristic of MCP in Botswana is short-term partnerships. In the PSI 2007 study, the reported timeelapsed since first sex with recent partners indicated frequent partner exchange (a finding that also hints atunder-reporting of total partner numbers per year by both genders).Although there are many positive societal forces that militate against multiple partnerships, there are alsosocietal factors that act as drivers of MCP. These factors include among others the fact that open discussionof issues relating to sex, sexuality and relationships is uncommon in most settings, whether media, communityor church meeting , school, family or couple. Difficult or controversial issues are mostly avoided in publicdebate, and couples tend not to discuss problems related to sex and relationships. Because of AIDS and familybreakdown, some of today’s young adults have grown up without positive adult and relationship role models.It is common for adults to avoid discussion of sexuality and relationships with children in order to protectthem from sex and HIV. Relationships with boy and girlfriends have to be kept secret from parents, eveninto adulthood; as a result, concealment of relationships becomes a learned behaviour and parents are lost aspotential protectors of their sons’ and daughters’ primary partnerships.

National Campaign Plan: Multiple Concurrent Partnerships5The socio-economic status of women relative to men remains unequal, gender-based violence is prevalentand men typically dominate decision-making relating to sex within relationships. For younger and poorerwomen, gender inequalities are magnified. Relationship norms that promote long-term, emotionally committedrelationships are lacking. Marriage rates are relatively low, with cohabitation which is not perceived to entailcommitments and obligations of sexual exclusivity or fidelity becoming increasingly common. The influenceof foreign media adds to unhelpful relationship norms by showing young people how others have multipleconcurrent partnerships with minimal consequences. Multiple bases and identities, physical separation fromprimary partners and ease of mobility also drive MCP. Many key informants to this campaign cited monetaryand material benefits as the main motivating factor for engagement with multiple partners.The economic backdrop of success and growth but increasing wealth inequality, the availability of modern,material goods and a consumerist culture means that those with greater wealth (usually men) have access toadditional sexual partners whose material needs and/or wants they can provide for (so-called ‘Range Rovermen’). A majority of those consulted during the campaign development process also cited alcohol as one ofthe major reasons for high HIV prevalence in their communities, due to the effects of impaired judgmentin sexual behaviour (including multiple and casual partners) caused by alcohol. A more detailed analysis ofsocietal factors that drive or inhibit MCP is presented at Annex 7. Among sexually active men and womenaged 15-34 surveyed by PSI in 2007, the following factors were shown to drive MCP: lack of knowledge aboutconcurrency and HIV risk, lack of peer social support for sticking to one partner, lack of self-efficacy to resistother partners, (for men) beliefs and attitudes about multiple partners, the belief that multiple partners areno problem if condoms are used, (for women) social norms about multiple partners, alcohol use, and lack ofpower to decide when one has sex. Detailed analysis from the PSI study of individual behavioural drivers ofMCP is presented at Annex 8.2.5 Can MCP Change?The campaign plan development process has confirmed high levels of concern about MCP and considerablewill to effect change in patterns of sexual partnerships, but also some doubts as to whether it is realistic toexpect change. However, the success of the ‘zero grazing’ campaign in Uganda in the early 1990s showed thatsignificant partner reduction can be achieved in Africa. The premise of the national MCP campaign plan is thatpatterns of sexual relationships in Botswana can change, given appropriate messages and a concerted, multisectoral,national effort. Complementary, supportive messaging on other risk-reduction behaviours, includingmale circumcision and condom use, as well as fundamental societal shifts in norms about sexuality and genderrelations will also be required if the campaign is to achieve success.

National Campaign Plan: Multiple Concurrent Partnerships63. STRATEGIC FOCUS OF THE CAMPAIGNThe overall behavioural objective of the national campaign is to reduce the percentage of the sexually activepopulation who are engaged in MCP. However, in light of the multi-faceted nature of MCP, it is necessary forthe campaign to make strategic choices about priorities and focus: which types of MCP, which target groupsand which key behavioural drivers, whether societal or individual.3.1 The Broader PictureMCP is not a single phenomenon and there are many ways, some more ‘traditional’ and some distinctlymodern, in which MCP manifests itself. Additional or overlapping sexual partnerships have a variety offunctions, as discussed above. The motivations, needs and environmental factors affecting the women andmen engaged in all of these MCP behaviours will be targeted by the campaign. This will beachieved by integrating MCP messages into existing one-to-one communication settings and into existinggender, age or other specific projects and channels. These opportunities include service and counsellingsettings, schools, life skills and empowerment programmes, peer education initiatives and state-, civil societyorfaith-sector groups and projects. It is also important to reiterate that campaign messages will distinguishbetween traditional polygamy and multiple partnerships that are not traditional. Similarly, where crossgenerationalrelationships are targeted by the campaign, a distinction will be drawn between marriage (andmarital fidelity) between men and women who are around ten years younger than them and older men whotake advantage of their relative power and affluence to engage in multiple partnerships with girls or youngwomenwho may feel they have little choice.3.2 Strategic Priorities: Populations and BehavioursAs noted above, by mainstreaming MCP messages into a wide range of ongoing projects and programmes, itwill be possible to reach many different populations engaged in different kinds of MCP for different reasons.However, the design and dissemination of media and community mobilization interventions will focus onthree strategic priorities. These strategic priorities, selected based on the estimated size of the target groupsand their susceptibility to behaviour change interventions, are:Young women engaged in MCP for personal or material gain;Men engaged in MCP for sexual variety; andCross-generational sexual partnerships between older men and young,vulnerable girls.Young women engage in MCP with wealthier, often older, men to satisfy a range of material needs and wants,or for advancement in education and employment. Particularly in urban areas, relationships whose functionis to provide for consumerist ‘needs’ are more common, and young women are often active agents in seekingdifferent or additional partners who can fulfil unmet needs in their life. However, in rural areas, women withchildren to care for and no earned income enter into multiple partnerships for basic needs such as food.The multiple partnerships young women form for material benefit include one-night, short-, medium- orlong-term partnerships. The additional partnerships may supplement a main partnership that meets moreemotional needs, or women may have different partnerships, all for different material motives.

National Campaign Plan: Multiple Concurrent Partnerships7The campaign will focus particularly on young women aged 18-24 years old. These are the years when womentypically have sex for the first time (according to BAIS II, the median age of sexual debut for women is 18.2years), and many young women of these ages have cross-generational relationships that expose them toparticularly high risks of HIV infection, as seen in the fact that HIV seroprevalence rates for women in thisage range is three times the rate for men of the same age.Men more typically have sidekicks, one-offs or overlapping short-term flings for sexual variety. There iswidespread, if often tacit, acceptance that men need more than one woman to satisfy them sexually, withreceived wisdoms such as ‘small houses strengthen relationships’ and ‘man cannot live on bread alone’supporting the norm. These relationships often have a compensatory function, providing benefits that arelacking in a main partnership (such as sexual experimentation that would not be considered proper with aprimary partner) or relief from stress, boredom or marital problems. Men who spend long periods of timeaway from their primary partners ‘need’ other partners to avoid enforced abstinence, while for others, alifestyle with multiple bases and identities (for example in town, in the home village and at the cattle post)makes it possible to maintain different women in different locations. Relationships that serve a function ofsexual variety for men are often the same relationships whose function for less wealthy, younger women ispersonal or material gain, with the man using his relative wealth to buy access to women whom he can affordto impress and maintain.The campaign will focus particularly on men aged 25-35 years old. Men in these years are typically movinginto the workforce for the first time, an experience that brings with it new opportunities and new advantages,including having the disposable income to support multiple partners concurrently (but generally without thedemands of having to support children). They are also particularly likely to be in jobs that necessitate regulartravel or base them away from their primary partners. Although men older than this engage in concurrentpartnerships, they will be less of a focus of the campaign, largely because they tend to be more set in theirways and so less likely to change their behaviour. Older men engaged in cross-generational relationships withyoung girls will be addressed separately under the next area.The phenomenon of older men taking advantage of the status conferred by their gender, age and relativewealth to have sex with girls and much younger women is of concern to many of those fighting to prevent HIVin rural areas. Key informants consulted during the development of the campaign plan repeatedly cited thesepartnerships as increasingly common and as a major barrier to HIV prevention. It is important to emphasizethat the partnerships that the campaign will seek to reduce do not include monogamous relationships thathappen to have an age gap of around ten years between the man and the woman: ten years is a relativelycommon age gap between long-term partners and it is concurrency that increases HIV risk, not an agegap per se. However, it is an inescapable, if uncomfortable, truth that there are men in our society whoabuse their positions of status and authority to take advantage of vulnerable young women or girls who aresocially conditioned to obey men and their elders. Although actual coercion is not common, the women feelpressured to have sex with the older men and unable to say no. The transactional element present in mostof these relationships further disempowers women to refuse sex, negotiate condom use or leave unwantedrelationships.

National Campaign Plan: Multiple Concurrent Partnerships83.3 Strategic Priorities: Underlying Causes of MCPThe evidence base gathered during the development of the campaign plan pointed to a number of structuralor societal factors that the campaign could focus on in order to reduce MCP, including taboos about sexin the public and private spheres, gender inequality, gender and relationship norms, lack of parent-childcommunication, mobility and physical separation from primary partners, consumerism and alcohol abuse.At the individual level data analysis also presented a variety of options for targeting behavioural drivers ofMCP, including lack of knowledge about concurrency and HIV risk, lack of peer social support for sticking toone partner and lack of self-efficacy to resist other partners. For men, beliefs and attitudes about multiplepartners and the belief that multiple partners are no problem if condoms are used could be targeted. Forwomen, alcohol abuse and lack of power to decide when one has sex could be addressed, while positive socialnorms about the undesirability of multiple partners could also be leveraged. In selecting target drivers of andbarriers to behaviour change to focus on during the campaign, the feasibility of changing different underlyingcauses of MCP through communications was considered. In analysing cultural drivers of MCP, effort wasfocussed on honing in on specific cultural factors that could be addressed through communications, ratherthan considering ‘culture’ as a single, daunting challenge.3.3.1 Young Women Engaged in MCP for Personal or Material GainEfforts to reduce the number of young women who actively engage in MCP for material gain or personaladvancement will focus on the following key drivers of MCP:(i) Knowledge that overlapping sexual relationships are more risky. The basic fact that concurrentrelationships increase the risks of HIV transmission will be a focus during the initial phase of thecampaign. Current knowledge levels among this target group are very low: in the PSI 2007 studyjust 19% were able to identify concurrent or overlapping relationships as being higher risk than nonconcurrentrelationships with a break in between.(ii) Consumerism and personal / material aspirations. This is the key societal driver of women’sdesire to engage in cross-generational partnerships. Related to materialism is young women’s beliefin their ability to resist the temptation to have other partners because of the materialbenefits they bring and a lack of peer support for primary partnerships. Young women’s lack of selfefficacy to resist engaging in MCP for material gain is often driven by stressful peer friendships basedon competition and affirmation around material goods. A focus of the campaign will thus be to shiftthe dynamic of young women’s friendships from competing to supporting each other in resisting thetemptation of engaging in MCP for material benefit.(iii) Future desirability as wives and mothers. Many young women do have aspirationsof future long term, stable relationships and marriage, but women who are ‘used up’ by older menare considered ‘finished’ and not desirable primary partners for men in their late 20s and 30s.The campaign will seek to use this conflict to show young women how engaging in MCP now can ruintheir future dreams.

National Campaign Plan: Multiple Concurrent Partnerships93.3.2 Men Engaged in MCP for Sexual VarietyCommunications designed for this target group will focus on the following underlying causes of MCP:(i) Knowledge that overlapping sexual relationships are more risky. Current knowledge levels amongthis target group are even lower than among young women: just 14% of men aged 25-34 in the PSI2007 study were able to identify concurrent or overlapping relationships as being higher risk than nonconcurrentrelationships with a break in between.(ii) Norms about gender and sexual behaviour. Concepts about masculinity, particularly malemalenorms, are a key societal driver of MCP: the more women a man has or can provide for, themore of a man he is. These concepts of masculinity are about how men rank themselves and eachother, and not about how women define what is desirable in a man. Therefore, the lack of peer socialsupport to have only one sexual partner will also be addressed because male bonding typically involvescompeting to have more partners.(iii) Lack of communication about sex within relationships. This is another key underlyingcause of MCP: because men lack the ability (more often than the motivation) to discuss sexual andrelationship problems with a primary partner, they find it easier to simply look for more or bettersex with somebody else. This is compounded by norms about gender and relationships inwhich women’s sexual fidelity is prized, expected and enforced by men, but neither men nor womenexpect a man to stick to one sexual partner, as well as by attitudes towards sex that de-link sexfrom relationships, emotional commitment and love.(iv) Men’s beliefs about all the benefits of having multiple partners and about their abilityto resist temptation to have other partners are linked to each other and to the abovedrivers of MCP. Greater knowledge about concurrency and HIV risk would affect men’s weighing of thebenefits and risks of MCP. Ability to resist temptation to have other partners relates to self image, peerpressure, inability to resolve problems with a primary partner and the ease of emotionally separating sexwith another partner from a primary relationship.The belief that having multiple partners is no problem if condoms are used will not be explicitly targetedby this campaign. Mixing partner reduction and condoms in the same message risks being confusing, if notcounterproductive. However, it is essential that this driver of MCP is addressed through careful, responsiblemessaging in all condom promotion programmes that does not undermine efforts to reduce MCP. This meansthat campaigns to promote condom use should avoid promoting condoms for use in multiple or casualrelationships or presenting condoms as a more attractive or feasible HIV prevention option than partnerreduction.3.3.3 Cross-Generational Sexual PartnershipsEfforts to reduce the phenomenon of cross-generational MCP characterised by culturally undesirabledifferences in age will focus on making it socially unacceptable for older men to take advantage of their statusand relative wealth to pressurise young girls to have sex with them, and on empowering girls to say no orwalk away from unwanted partnerships with older men.

National Campaign Plan: Multiple Concurrent Partnerships10Currently, taboos about public discussion of sex and HIV allow the men who engage in multiple relationshipswith young girls a certain degree of impunity. Even if others in their communities know and disapprove ofwhat they are doing, nothing is said publicly. The campaign will work through faith-based and other institutionsto promote more open, honest comment on these relationships and thus create shame and stigma thatcauses the men to question their behaviour. This is a controversial issue, but one that the campaign will notshy away from addressing.Complementary interventions will focus on increasing girls’ self-efficacy to refuse sex with older men, evenif they have already accepted money or gifts; creating the necessary social support from authorities that girlsneed to get out of cross-generational partnerships in which they feel trapped; and building girls’ self-efficacyto seek such support and parents’ ability to talk to their children about growing up, sexuality and relationships.Integration of MCP programming into existing initiatives at the community level will prioritize life skills andempowerment programmes targeting vulnerable girls and young women, as well as parenting skills.3.4 What Will Success Look Like?It is important for the campaign to have, in addition to a strategic focus on priority target populations engagedin MCP, specific risk behaviours they are engaged in and underlying causes of risk behaviours, a clear visionof the desired changes. This includes changes in the types and patterns of sexual relationships practicedby different target populations, and changes in structural factors, values, norms and individual ability andmotivation to change behaviour. It is this vision that will be used as a basis for evaluating the extent to whichthe strategic priorities of the campaign have been successfully addressed.At the community level, the campaign aims to bring about more open debate about HIV and AIDS, MCP andthe underlying causes of MCP as social issues, from which community-owned responses to social problemsare generated. This will include debate on why older men are permitted to have sex with other men’sdaughters, and why some parents even turn a blind eye to their daughters having sex with men older thantheir fathers. Debate in the national media will serve as a catalyst for debate in kgotlas, churches and othercommunity institutions. Within families, parents will gain the motivation, skills and confidence to talk totheir children about growing up, sexuality and relationships, and norms about parental recognition of theirchildren’s boy- and girlfriends will shift.Girls will form relationships, but these will be with boys their own age and non-sexual. They will suffer feweradvances from older men, but if approached they will be able to say no, and if they are pressured or coercedby older men they will be able to seek support. Older men will self-censure and refrain from approachingyoung girls for sexual relationships, because public comment about inter-generational sex has made it sociallyunacceptable.More young women will stick to one partner at a time, and these will be men for whom they are theprimary partner. Although young women will naturally have different relationships as they are growing up, eachrelationship will be monogamous and they will take breaks in between relationships. The main motivation foror function of young women’s relationships with men will shift from being about material gain to being aboutfinding love and commitment. The nature of peer friendships between young women will change, and peeraffirmation will be based on character and personal achievement rather than on material possessions.

National Campaign Plan: Multiple Concurrent Partnerships11Young women will encourage each other not to trade dignity for material possessions and support eachother’s positive choices. It will become normal for men to have sex only with their primary partners, whoare women to whom they have an emotional commitment. Male peer friendships will be supportive andprotective of primary partnerships and men will share knowledge about ways to resolve sexual and relationshipproblems within primary partnerships and encourage each other to resolve problems rather than takingother partners. Male-male norms will shift to include positive affirmation of those who resist temptation tohave other partners, and HIV risk will feature prominently in discourse between men about the costs andbenefits of having multiple partners. Couples will gain the skills and confidence to talk to each other about sexand relationship problems and norms about the importance of relationships and sexual fidelity will shift. In themedia and in community institutions, men and women will see alternative attitudes about sex, relationshipsand fidelity, masculinity and womanhood role-modelled.

National Campaign Plan: Multiple Concurrent Partnerships124. PROMOTING BEHAVIOUR CHANGE4.1 Approach to Behaviour ChangeThe campaign’s approach to behaviour change will be based on premise that sustained behaviour change canonly be achieved if there is a desire to change within the individual and if there is an enabling environmentfor adopting and maintaining new behaviours. To create desire to desist from MCP within individuals, thecampaign will adopt a consumer-centred approach that does not simply tell women and men to ‘do this’or ‘don’t do that’. Target audiences will be offered clear alternatives to their current behaviours, and thesealternatives will be promoted, or positioned, by means of benefits that are relevant, attractive and importantto people’s lives. At the same time, the campaign will shift perceptions of the risks and costs of MCP, so thatpeople’s evaluation of the costs and benefits of multiple partners alters and the benefits of sticking to onepartner outweigh those of having more than one partner. To create an enabling environment for adoption andmaintenance of new behaviours, the campaign will focus on the values and norms that shape target groups’lives. Behaviour change will be promoted via approaches that stimulate debate, drawing on cultural traditionsof oral communications, dialogue and group interaction, and acting as a catalyst for target groups to generatetheir own ways of overcoming barriers to behaviour change. Communications will present and role-playalternative values, norms and scripts to those that are currently driving MCP in ways that are, while leveragingpositive cultural norms and values, thus targeting the points of conflict about MCP that exist within the mindsof target audiences.Different messages will be developed for different target groups, and messages will evolve over time: (a)to keep the campaign fresh and (b) to provide solutions to needs and challenges as target groups gainawareness, reflect and attempt to change and maintain behaviour. At each stage of the campaign, messageswill focus on specific themes appropriate to the stage of behaviour change that best characterises the targetgroup. Messages will be designed to promote both individual reflection and discussion among peers, primarypartners and families. Each phase of messaging will build on the last, with target drivers of MCP that are easierto address and/or are pre-requisites for addressing other drivers being tackled first.4.2 Campaign IdentityAlthough specific messages will evolve and stay fresh, the campaign will carry a central, unifying message ofthe campaign, which will be maintained for its entire duration. A campaign symbol / slogan will be createdthat commands attention, creates momentum and belonging, and promotes a consistent central message.This central message will be prominently displayed on signage everywhere that MCP is being addressed (forexample, banners in public places and posters in clinics, schools and churches). The campaign symbol will alsobe prominent in mass media communications and on all communications materials created for the campaign.The central, unifying slogan of the campaign should become common currency in everyday dialogue, in theprivate sphere, in community settings and in the media.

National Campaign Plan: Multiple Concurrent Partnerships134.3 Reducing MCP among Young WomenYoung women will need to be compensated for the loss of the money, goods, lifestyle, peer prestige and maleappreciation that they gain from MCP if they are to change their behaviour. By sticking to one partner ata time, they will gain self-worth, dignity, a more secure or less fragile sense of who they are, freedom fromthe stress of competing with friends over men and gaining approval from peer opinion leaders about theirmaterial belongings, and better long term relationship prospects, as well as reduced HIV and pregnancy risk.The key challenge with this target group will be that the benefits of MCP are immediate and tangible and thebenefits of changing behaviour are intangible and take time to be felt.The first phase of the campaign will focus on simply raising awareness about concurrency and HIVrisk. The key objective of this phase will be to change young women’s evaluation of the material benefits ofMCP when weighed against the HIV risk, which will be critical in priming young women for the subsequentphases of the campaign and making them more open and receptive to the alternative behaviours and valuesthat will be promoted.After the initial awareness-raising phase, messages for young women will promote self-worth anddignity as benefits of sticking to one partner and being in a relationship that is characterised by emotionalcommitment rather than transaction. Self-worth and dignity will be part of an alternative sense ofwhat it means to be a woman that is secured in culture and roots and is not dependent on measuringoneself materially against others, as well as being about achieving one’s aspirations through one’s own efforts.This also involves not being an ‘easy’ woman whose character is questioned by many outside her peer group,and even by the men she is sleeping with.Complementary messages that provoke young women to reflect on the kind of women that they want to benow and in the future will appeal to long-term relationship aspirations to motivate them to reassessthe costs associated with the short-term material benefits of MCP. Young women do idealise future,stable, loving partnerships, but the men with whom they will eventually want to form these partnerships lookupon women who have been with many men or older men as ‘easy’, ‘used up’ and ‘finished’, and not as suitablelife-partners or mothers for their children. Communications will role-play stable, loving partnerships withall the practical and emotional benefits they offer, and show young women how they can work towards thislifestyle.Variations on these messages will promote positive affirmation of young women by friends andparents based on dignity, character and personal achievement; between peers, this will include affirmation ofnot being easy or getting involved with different men for material gain, but being the kind of woman that anyman would be proud to have as a wife or as a mother to his children.4.4 Reducing MCP among MenMen will need to be compensated for the loss of the fun, peer prestige and sexual gratification associatedthat they gain from MCP. By being faithful to their primary partner, men will gain a surer guarantee of theirpartner’s fidelity, more honest relationships with their mothers and children where the most importantpeople in their lives are proud of who they really are, and freedom from the fear of sidekicks interfering intheir primary partnerships, as well as reduced HIV risk.

National Campaign Plan: Multiple Concurrent Partnerships14By focussing on their primary partner, they will also develop the ability to resolve sex and relationshipproblems, leading to greater sexual satisfaction (further reinforcing their primary partner’s fidelity). Finally,they will benefit financially, becoming free from the stress of impressing and maintaining different partnersand gaining more money to spend on their children. As with young women, there is a critical communicationschallenge with men, namely that the sexual benefits of MCP are immediate and tangible and the benefits ofchanging behaviour are intangible and take time to be felt.The first phase of the campaign that focuses on raising awareness about concurrency and HIVrisk will be key in priming men for the subsequent phases. By focussing on knowledge and risk perception,early messages will change men’s evaluation of benefits of MCP, such as choosing among different partners,ease of moving on if one partnership ends, peer prestige from having different partners, sexual satisfaction,and never having to sleep alone. The first communications challenge of the campaign will be to reduce men’sperception of the net benefit of MCP when weighed in a more informed way against the HIV risks involvedin concurrency and thus make them more open and receptive to the alternatives and solutions that willsubsequently be promoted.After awareness-raising, messages for men will promote more satisfying primary partnerrelationships as the benefit of sticking to one partner, alongside alternative mindsets about masculinityand sex. The campaign will promote new norms about masculinity that are not about bedding morewomen than the next man, but about being a son and father to be proud of, and a lover whose woman wouldnever need to look elsewhere. As with young women, promoting new values will involve a communicationsobjective relating to changing the nature of peer friendships. The campaign will promote new norms aboutmale friendships where harmful competition to have more partners is replaced by male friendships thatsupport each other’s primary partnerships.At the individual level, key to promoting relationships will be equipping men with the tools and confidenceto communicate with their primary partner about sexual and relationship issues and problems, because anoften-cited motive for taking other partners is lack of sexual satisfaction within the primary partnership. Thekey benefit for men of better communications within relationships will be healthier, more stable andmore sexually satisfying primary partnerships. Once men cease to look elsewhere for sexualsatisfaction and variety, they will also benefit from reduced stress about interference (for example unwantedpregnancy) in their primary relationships and a surer guarantee of their primary partner’s fidelity: a womanwho is sexually satisfied and does not need revenge is much likely to be unfaithful.Finally, the campaign will promote a mindset in which sex is linked to relationships, love andemotional commitment. This will be complementary to promotion of primary partnerships because mencurrently find it easy to mentally de-link looking for sexual satisfaction elsewhere and their emotionalcommitment to their primary partner.4.5 Stages of Behaviour Change and Evolving MessagesThe illustrative messaging sequence targeting young women is presented below in order to demonstrate thecampaign’s approach to messaging. This approach is based on known drivers of risk behaviour and barrier tobehaviour change and on behaviour change theory relating to stages of change.

National Campaign Plan: Multiple Concurrent Partnerships 15Phase 1Current behaviour and drivers: have different, older partners to provide material benefits that they cannot afford themselves; competewith friends over material goods, in order to be like their role models, namely those who have more than they do.Current stage of behaviour change: have general awareness about HIV but lack specific awareness about MCP risk; are notthinking about changing behaviour or are rationalizing reasons not to change, such as needing the material benefits that older partnersprovide and having low expectations of male sexual fidelity.Message focus: knowledge about MCP riskCommunications objectives: young women reassess and discuss the HIV risk associated with their relationships with oldermen.Phase 2Stage of behaviour change: now aware that having concurrent partnerships puts them at risk of HIV, and more concerned that theyare putting themselves at risk; however, they have no other way to obtain the material goods they need to keep up with peers andimprove their lives, and their male partners still have other partners.Message focus: materialismCommunications objectives: young women are encouraged to reassess the importance of material goods relative to the HIVrisk of the sexual partnerships they entail.Phase 3Stage of behaviour change: aware of MCP risk and motivated to try to reduce partnerships with older men; however they are finding itdifficult to resist the temptation of the material goods that others are still receiving; also still sure that their boyfriends and olderpartners have other partners.Message focus: dignity / self-worthCommunications objectives: young women question what makes them who they are – what they own or wear, or their culture,roots, character and personal achievements, and begin to see an alternative identity portrayed and championed around them.Phase 4Stage of behaviour change: aware of MCP risk and motivated to try to reduce partnerships with older men; however they are findingit difficult to resist the temptation of the material goods that others are still receiving; also still sure that their boyfriends and olderpartners have other partners.Message focus: future relationship aspirationsCommunications objectives: young women think about the costs of MCP not just in terms of HIV risk, but in terms ofundermining their future relationship prospects if men view them as ‘used up’; they do not want to be viewed as ‘easy’, either now orin the future.Phase 5Stage of behaviour change: reappraising the costs and benefits of MCP for material gain and reducing partnerships; however, it is hardto be different to their friends so even though they have fewer older partners, they cannot resist all the time; they still know that theirboyfriends and older partners have other partners anyway and are concerned about this risk.Message focus: peer social supportCommunications objectives: as more young women desist from MCP, new norms about real friendship develop, involvingpositive affirmation between peers for being true to themselves and not going with older men for material gain.Phase 6Stage of behaviour change: young women have accepted that the risks of partnerships with older men outweigh the material benefits,and are supporting each other to resist temptation, stay safe and keep their dignity; lapses are now driven more by their primarypartners’ infidelity than by material gain.Message focus: self-efficacy to confront and, if necessary, leave an unfaithful partnerCommunications objectives: young women receive encouragement from their friends and family to take control of HIV risk intheir lives and no longer tolerate men whose engagement in MCP puts them at risk.

National Campaign Plan: Multiple Concurrent Partnerships 165. ROLLING OUT THE CAMPAIGN5.1 Importance of LeadershipThe fundamental shifts in behaviour and the social and environmental factors that drive MCP will requirevocal and concerted leadership in all sectors and from the highest level to the village level. The campaign willhave the greatest chance of success if political, traditional, faith and civil society leaders:Use every opportunity to talk about MCP;Support mainstreaming of MCP messaging in their institutions’ or sectors’ daily activities;Talk publicly about how and why sticking to one partner can turn back the spread of HIV transmissionand affirm their belief that behaviour change is possible;Demand action on the social and environmental factors that drive MCP;Initiate debate about the drivers of MCP and generate solutions;Discuss HIV and MCP as a social issues, with social solutions;Engage personally in driving needed social change;Advocate for supportive policy interventions and changes; andBecome personally involved in mobilizing the resources needed to bring about changes in norms andbehaviour and build capacity to roll out the campaign.The campaign is unlikely to succeed if it shies away from potentially controversial issues relating to societalnorms that contribute to the practice of MCP. Sensitization and advocacy efforts will be conducted in amanner respectful of traditional values, but will also adopt a ‘business unusual’ approach where previouslytaboo subjects are brought out into the open where necessary.5.2 SensitizationIn order to achieve this leadership, the campaign issues need to be placed at the top of key policy, social andresource agendas. The first step in the rollout of the campaign will be the recruitment of a team of ‘MCPambassadors’: acceptable, credible opinion leaders who can address, sensitize and engage key individuals andinstitutions, including the Office of the President, the Values Commission, Parliament, the House of Chiefs, theNational AIDS Council, the faith-based community, the Men’s Sector, and the Ministries of Health, Education,Youth, Sports and Culture, and Local Government.The MCP ambassadors will mobilize key focal points within these sectors and institutions and work withthem to determine how they can mainstream MCP messages, promote debate about behaviour changeand social issues related to MCP and advocate for social and policy change. At the same time, tailoredMCP sensitization packs and toolkits will be made available to different sectors with information, scripts,presentations and materials that they can use to disseminate campaign messages, and additional resource andsupport requirements will be identified.The ambassadors and others leading the engagement of key sectors in the campaign rollout will take care topromote involvement in the campaign to leaders, and through them to foot-soldiers, within each sector orinstitution in ways that demonstrate the benefits of getting involved and integrating MCP messaging into theiractivities and address concerns about the costs of participating.

National Campaign Plan: Multiple Concurrent Partnerships 175.3 Management and CoordinationThe campaign will be managed and coordinated through existing national- and district-level structures, underthe leadership of NACA.5.3.1 National LevelAt national level, a campaign coordinating unit will be established in the BCIC Division of NACA, staffed bypersonnel on secondment. The campaign coordinating unit will comprise the following staff members:National Campaign Coordinator, responsible for overall campaign management, including overseeingthe rollout of the campaign at national- and district-levels, managing the campaign coordinating unit,and supporting the advocacy efforts of campaign Ambassadors;National Campaign Support Officer / IEC Officer, responsible for working at the national level withrelevant government and civil society partners to integrate MCP messages into existing and plannedactivities, and for working with the media;Two (2) District Support Officers, responsible for providing support to district stakeholders indeveloping district campaign plans, providing training and other technical assistance, and managinginformation flows between the centre and districts; andMonitoring & Evaluation Officer, responsible for documenting the implementation and success of thecampaign against its performance indicators.The campaign coordinating unit will be supported by the lead technical agency. This entity will provide technicalassistance across the various dimensions of the campaign, and will have specific responsibilities for leadingthe development of messages that can be used by the range of partners involved in the campaign (in orderto ensure that consistent messaging is used throughout the country) and for conducting research and somemonitoring and evaluation activities. PSI has been selected as the lead technical agency for this campaign.For advocacy and sensitization efforts, the campaign coordinating unit will be supported by the MCPambassadors described above.The campaign coordinating unit will report its progress regularly to the National HIV Prevention TechnicalAdvisory Committee (TAC) and other relevant structures. The TAC has already constituted an MCP CampaignSub-Committee, which includes the Ministries of Health, Local Government, Youth, Sport, and Culture, andEducation, ACHAP, PSI, Tebelopele, Pathfinder International, BOCAIP and UNICEF. This sub-committee willcontinue to play an active role in supporting the work of the campaign.Figure 5-1 depicts the national management and coordination structure.

National Campaign Plan: Multiple Concurrent Partnerships 18National levelFigure 5-1 Proposed national management and coordination structuresNational HIVPreventionTechnical AdvisoryCommitteeTAC MCPsubcommitteereportingadviceCampaignCoordinatingUnitsupportNACAsupportLead TechnicalAgencyCampaignAmbassadors5.3.2 District LevelThe structure of management and coordination at the district level is similar to the structure at the nationallevel. The Office of the District AIDS Coordinator (DAC) will assume overall leadership for MCP activities atthe district level. There will not be full-time MCP campaign personnel at district level, but DACs will identifykey personnel (such as the Health Education Officer, Monitoring and Evaluation Officer, Assistant DAC andPeace Corps Volunteers) who can dedicate a proportion of their time to the campaign and form a districtcampaign coordination team. This will include a district campaign coordinator who will be nominated fromthe district campaign team and who will report on MCP campaign progress to the DAC. The work of theseteams will be supported by existing structures such as the IEC Technical Working Groups of the DistrictMulti-Sectoral HIV/AIDS Committee. The teams will also be responsible for mobilizing Village Multi-sectoralHIV/AIDS Committees (VMSACs) and Village Health Committees. The district campaign coordinators willpresent monthly progress reports to the national campaign coordinating unit through the Ministry of LocalGovernment.Once nominated, district campaign coordinators will attend a national training workshop and will receive supportfrom the national campaign coordinating unit to sensitize key district stakeholders and develop districtcampaign rollout plans. The motivation of the district campaign coordinators will be key to the campaign’ssuccess, so the national campaign coordinating unit will be charged with ensuring that district coordinatorscan access the resources they need, receive recognition and (non-monetary) reward for their efforts, and arelistened to rather than imposed upon.Figure 5-2 describes the district management and coordination structures.

National Campaign Plan: Multiple Concurrent Partnerships 19Figure 5-2 District management and coordination structuresThe primary responsibilities of the district campaign teams will include development of district workplans andbudgets, mobilization of district stakeholders to get involved in the campaign, coordination of MCP activitiesto ensure cohesive messaging and avoid duplication, adaptation of national materials to meet local needs anddisbursement of funds. District campaign teams will engage stakeholders with technical expertise and targetgroup insight including youth officers, social workers, public health specialists and CBO / FBO personnel.District rollout plans will identify steps to be taken and resources required to:Engage district and village leaders personally in reducing MCP and addressing the factors that drive MCP;Sensitize stakeholders across sectors and equip them with the information and tools they need todisseminate MCP messages and address related campaign themes; this includes Chiefs, DistrictCouncils, District Development Committees (DDCs), health workers, schools (teachers, PTAs), churchesand FBOs, the Men’s Sector, youth groups, sports and cultural clubs / groups, Business Councils, andCBOs projects in all development sectors;Reinforce the MCP messages in the national media by integrating MCP into the regular activities ofinstitutions and projects at the community level;Equip those key individuals to whom others look for information and advice have with sufficientinformation and materials about HIV and MCP to answer questions; these key campaign alliesare likely to include Chiefs, District Councillors, DMSAC members, DDC members, teachers, pastors,health workers, community nurses, VCT counsellors, lay counsellors, youth leaders, peer educators andCBO workers;Make the campaign highly visible in people’s everyday lives using campaign branding: plans should quantifythe amount of branding items needed; andPromote debate about the key campaign themes, including MCP and HIV risk, the acceptability of talkingabout sex, the unacceptability of old men having sex with young girls, MCP as a social issue requiringsocial solutions, the importance of parent-child communications, gender relations, relationships, and whatit means to be a man or woman are in DMSAC meetings, kgotla meetings, community events, communitytheatre, counselling and inter-personal settings, peer education projects, schools, church sermons andfaith, youth and men’s sector groups or clubs.

National Campaign Plan: Multiple Concurrent Partnerships 205.4 Content DevelopmentAt the national level, creation of campaign messages, materials and media will be driven by the lead technicalagency (LTA), drawing on expertise within the multi-stakeholder national campaign team and engaging creativeagencies, implementing partners and target groups. Content development will follow the following process:Content developed nationally will include campaign branding, sensitization packs, media spots and jingles,campaign signage (banners, posters, clothing, etc), information and educational tools for one-on-one, smallgroup and community settings and MCP modules that can be incorporated into professional training. All ofthese materials will be made available in electronic format to district campaign teams and implementing partnersso that they can be adapted for specific contexts or target audiences or incorporated into existing communicationsmaterials. The national campaign team will offer assistance to districts and partners who requestit adaptation or mainstreaming of MCP materials and messages. The first campaign content to be developedwill be the campaign branding. This includes the rallying call to action slogan that will be used on all campaignmaterials and signage throughout the duration of the campaign, acting as a unifying theme and message. Thebranding package will also include a logo and templates (colours, fonts, designs) to be used in all materials,including media, sensitization packs and communications tools and materials.At the same time, tailored sensitization packs will be created for policy makers, the media, businesses / worksites,the youth sector, churches and FBOs, the health sector and educators. Some content will be commonand some specific to the needs and interests of each of these key secondary target groups. Sensitization packswill include factsheets on MCP and HIV risk and the drivers of MCP, a summary of the national campaign plan,examples of brochures and signage, a CD containing the campaign plan, presentations, campaign branding andMCP materials, a ‘what you can do’ list and guidelines on MCP programming and communications.

National Campaign Plan: Multiple Concurrent Partnerships21The initial phase of messaging for media spots and communications materials will focus on raising knowledgeand awareness about concurrency and HIV risk. Sufficient information is available on which to base developmentof this content and there is no need to engage target groups before the concept and message testing stage.Prior to development of subsequent phases of messaging for media spots and communications materials, thecampaign’s positioning strategy will be tested with target groups in order to refine understanding of targetgroup perceptions of key campaign themes such as communication within relationships, materialism, attitudesto sex without emotional commitment, peer friendships, and the costs and benefits of desisting from MCP.Target groups in urban, rural and remote areas will be engaged at key stages of the content developmentprocess to test concepts, key messages and more detailed content for likeability, understanding and interestin knowing more, and to ensure that the messages being taken away meet the campaign’s communicationsobjectives. During concept and message development, target group research will engage both those who areengaged in MCP and those who are not, to compare their perspectives and motivations. As each phase of thecampaign rolls out, listener groups will be used to ‘take the pulse’ of different target groups to ensure that thenext phase responds appropriately to the ways in which the current phase has changed perceptions of risk,and of the necessity, desirability and feasibility of change.5.5 Channel MixA range of interpersonal, community and media channels will be used to disseminate campaign messages.These may include: interpersonal interventions such as one-on-one and small group discussions in households,churches, schools, and workplaces (through peer education or utilizing outreach workers); communitytheatre; facilitated community debates; banners, posters and danglers in public locations and service sites;media spots and jingles via radio, television, newspapers and magazines and billboards; radio and televisiondramas; and inter-personal media channels such as SMS, email (footers), advice slips and call waiting messages.Private companies and government institutions will be approached to rollout MCP messages through theinter-personal channels at their disposal. DMSACs and other grant-makers will have budgets for CBOs andcommunity theatre groups who want to implement grassroots projects focussed specifically on MCP.Through both media channels and IEC materials for grassroots interventions, the campaign will use stories,drama, discussion and other inter-active methodologies to stimulate debate of key issues and audiencegeneratedsolutions. Media and community level interventions will feed off each other, with media channelsbeing used as a catalyst for community level debate, key questions arising at the community level beingcaptured in national media commentary and local solutions and successes being celebrated in the media. Thecampaign will also engage artists such as musicians, comedians, poets and theatre actors whose media givethem the freedom to expose secrets and taboos in a creative and non-threatening manner, and equip themwith the information they need to incorporate MCP themes into their acts.

National Campaign Plan: Multiple Concurrent Partnerships225.5.1 Mainstreaming MCP MessagesThere are many potential opportunities to leverage existing communications initiatives on HIV/AIDS andsexual and reproductive health, and integrate messaging and debate about MCP and its underlying causes intoongoing activities at little financial cost. A diverse range of stakeholders from the health, education, media,labour, business, youth, civil society and faith-based sectors participated in the development of the nationalcampaign plan. These future implementing partners identified specific projects, activities and services intowhich they can integrate MCP messaging, given the necessary support in terms of sensitization, informationand materials, including:Prevention of mother-to-child (PMTCT), antiretroviral therapy (ARV), isoniazid preventive therapy (IPT),and sexually transmitted infection (STI) clinical services, both at facilities and through home visits andcommunity health worker services;Voluntary and routine HIV counselling and testing;Youth life skills and role model programmes, the youth forum and school rallies;Couples counselling and parenting skills programmes;Prevention with positives and projects providing care and support to people living with HIV/AIDS;Community mobilization, peer education, community theatre and male involvement projects;Church sermons and prayer meetings;School and varsity classes and extra-curricular activities;Health and wellness fairs;Media health segments, children’s and youth programming, phone-in talk shows and news reporting;The Makgabaneng radio drama, teen magazine, and listener groups;Workplace HIV and wellness programmes in the public and private sectors; andProfessional training curricula and workshops in all sectors.5.6 AdvocacyThe MCP ambassadors will engage key state and civil society institutions to advocate for policy interventionsto address social drivers of MCP. For example, physical separation from primary partners leads to men andwomen taking other partners and makes it easier to maintain different partners in different locations. Advocacycould focus on changing the practice of posting public sector workers away from their families, workingwith institutions such as the Directorate of Public Service Management. A lack of communication about sexand sexuality within families and relationships, and girls’ lack of ability to reject the advances of older menare also important societal drivers of MCP that could be addressed by supportive policy interventions thatincreased the resources for and reach of parent training, couples counselling and life skills programmes.The ambassadors will also engage Ntlo Ya Dikgosi (House of Chiefs), the faith-based community and otherkey custodians of social norms whose voices can shape media and community debate about MCP, the importanceand feasibility of change, and key societal drivers of MCP such as taboos about discussion of sexand HIV/AIDS, gender norms within relationships, gender inequality and parent-child communications. Publicsupport from respected national and local opinion leaders will be necessary if society is to accept some ofthe difficult and challenging messages of the campaign.

National Campaign Plan: Multiple Concurrent Partnerships23Changing gender norms will be one of the most difficult but one of the most critical and fundamentaldeterminants of the campaign’s success. Campaign ambassadors will use every available opportunity foradvocacy and mobilization with political, cultural and youth leaders, and the gender-related issues thatperpetuate MCP and HIV transmission, and for building consensus about the need for some fundamentalsocietal changes relating to gender.Finally, there will be a need for advocacy targeting public and private sectors as well as international donorsto ensure that the resources necessary to rollout the campaign are available, as well as on behalf of othersupportive programmes such as couples counselling, youth life skills and parenting skills. The campaign’sambassadors will advocate to media houses and the Ministry of Communications, Science and Technologyfor zero-cost transmission of campaign communications, and will also advocate to major private sectorcompanies for flighting of campaign messages and materials at zero-cost in stores, on transport and via SMS.5.7 Schedule for RolloutThe table on the following page present timelines for rollout at national and district levels of the campaign activitiesdescribed above.

National Campaign Plan: Multiple Concurrent Partnerships24

National Campaign Plan: Multiple Concurrent Partnerships256. RESEARCH, MONITORING AND EVALUATION,AND LOGICAL FRAMEWORK6.1 ResearchAs discussed above, the concept of “MCP” encompasses a number of discrete behaviours with a variety ofmotivations. Understanding these phenomena is critical to designing successful interventions, so research willplay an important role in the campaign. Four types of research will be included:Quantitative surveys that measure the extent of MCP and attempt to distinguish significant determinants of MCP;Qualitative research that allows those engaged in (or choosing not to be engaged in) MCP anopportunity to talk about MCP in their own terms, thereby providing more nuanced perspectives onthe phenomena;Operations research that identifies ways to improve the efficiency and effectiveness of programmaticinterventions, and that assesses the costs and cost-efficiency of the campaign;Modelling work that characterises the nature and density of the sexual networks in Botswana.Some of this research has already begun, and it will continue over the duration of the campaign.6.2 Monitoring and EvaluationMonitoring of the national campaign plan will be conducted on quarterly, semi-annual and annual bases. Themonitoring plan aims to balance two key objectives: (1) to gather sufficient information to measure campaignimplementation achievement of objectives and inform ongoing campaign planning; and (2) to minimise theadministrative burden to implementers of mainstreaming MCP messages in their ongoing activities. Campaignmonitoring at district level will be integrated into existing mechanisms to the maximum extent possible, withthe desire of minimizing the imposition on district personnel (e.g., by simply adding extra lines on the monthlyforms they already complete).Quarterly monitoring will document the extent to which the campaign rollout schedule is being followed andwill focus on process indicators relating to development of district campaign plans, distribution of materials,flighting of media communications and disbursement of funds. Semi-annual campaign reports, compiled by thenational campaign coordinator, will document successes, lessons learned and recommendations from districtsand implementing partners for improving the rollout. Annual quantitative studies will measure changes inbehaviour and individual behavioural drivers as well as exposure to different MCP message sources; thiscampaign monitoring will be complemented by qualitative studies to ‘take the pulse’ on how norms aboutMCP and other key campaign themes are changing as the campaign rolls out.Campaign evaluation will guide broader policy decisions on HIV prevention at district and national levels.Evaluation will be conducted via mid-term and end of campaign reviews. The mid-term review will focusprimarily on output-to-purpose evaluation to ascertain whether the campaign is on the right track andwhether revised messaging and channel strategies are needed. The mid-term review will be conducted by thenational campaign team with consultant support. The end of campaign review will focus on purpose-to-goalevaluation and be conducted by an external party.

National Campaign Plan: Multiple Concurrent Partnerships266.3 Logical FrameworkThe logical framework below sets out the indicators against which the national campaign coordinating unitwill report to NACA (through the National HIV Prevention Technical Advisory Committee [TAC]), and theinformation they will collect from districts and implementing partners. The logframe will be updated withquarterly and annual targets as workplans are developed and budgets made available. Once workplans andconfirmed budgets are in place, quarterly targets will be presented to and approved by NACA and the TAC,and reporting to NACA and the TAC will be against these agreed targets.The broad target audience captured by the logical framework indicators (sexually active men and womenaged 15-49) reflects the campaign’s approach of reaching different groups engaged in different MCP risk behavioursthrough diverse community-level and media channels and by engaging a broad range of implementingpartners in the dissemination of MCP messages.

National Campaign Plan: Multiple Concurrent Partnerships27

National Campaign Plan: Multiple Concurrent Partnerships281 Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa, Maseru,Lesotho 10-12 May 2006, Report SADC July 2006.2 The Mid-term of the Botswana National Strategic Framework for HIV/AIDS 2003-2009: On the Road toVision 2016, NACA / SIDA / ACHAP 2007.3 Makgabaneng Radio Serial Drama Listenership Survey Report, Botswana May 2005. Katina A. Pappas-DeLuca1, PhD, Todd Koppenhaver2, MHS, and the Makgabaneng Listenership Survey Group, 2003.4 “A Bull Cannot be Contained in a Single Kraal’’: Concurrent Sexual Partnerships in Botswana”, Carter et al.,AIDS Behav., 2007;11(6);822-830.5 Botswana AIDS Impact Survey II: Popular Report and Statistical Report, March 2005, NACA in collaborationwith CSO and other development partners.6 Epidemic of Inequality Women’s Rights and HIV/AIDS in Botswana & Swaziland: An Evidence-Based Reporton the Effects of Gender Inequity, Stigma and Discrimination. Physicians for Human Rights 2007.7 HIV Prevention: Multiple Concurrent Partnerships Report, PSI-Botswana / Choose Life!, August 2007.8 Survey of HIV and AIDS related knowledge, attitudes & practice, CIET Trust 2008.9 “Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS in Botswana”,Kalichman et al, Sexually Transmitted Infection 2007;83;371-375.

ANNEXES

National Campaign Plan: Multiple Concurrent Partnerships30Annex 1. EPIDEMIOLOGICAL AND POLICY CONTEXTHIV PrevalenceGlobalAccording to the UNAIDS Global Epidemic Update (2007), the estimated number of persons living withHIV worldwide in 2007 was 33.2 million. Every day, over 6800 persons become infected with HIV and over5700 persons die from AIDS, mostly because of inadequate access to HIV prevention and treatment services.Sub-Saharan Africa continues to be most disproportionately affected with 22.5 million people living with thevirus. More than two thirds (68%) of all HIV-positive people live in Sub-Saharan Africa where more than threequarters (76%) of all AIDS deaths in 2007 occurred. Unlike other regions, the majority of people living withHIV in sub-Saharan Africa (61%) are women.NationalBotswana is one of the countries in Southern Africa most impacted by the HIV/AIDS pandemic with currentHIV prevalence estimated at 17.1% for the total population; 19.8% of females and 13.9% of males (BAIS II) .Sentinel surveillance data of pregnant women aged 15-49 years estimated HIV prevalence at 33.4% in 2005(GOB 2005). In response to the alarming rates, the Government of Botswana has made a strong commitmentto provide care and support to those infected and affected by HIV/AIDS and to prevent further transmissionof the virus through development of systems to serve as coordinators of national HIV interventions.In measuring knowledge about HIV/AIDS through the BAIS II, data showed that most of the respondents wereknowledgeable about HIV/AIDS and risk factors. The most often cited risk factors for getting an STI werereported to be: unprotected sex (97%) and having many sexual partners (98%). However, when asked aboutways to prevention transmission of HIV 82.4% of respondents were aware of at least one way of preventingHIV transmission. The ‘use of condoms’ was the most reported method (72.6%) to prevent HIV transmission,followed by ‘no sex at all’ (50.7%). The least identified means of protection from HIV transmission was beingfaithful (21%). BAIS II also found that the prevalence rates were high among persons living together, separatedand divorced at 31.5%, 30.2% and 29.2 in that order.Focus of HIV Prevention InterventionsGlobalGlobally it is recognized that there is the need for increased and a scale up of current prevention efforts.Based on UNAIDS data, a 2003 report from the Global HIV Prevention Working Group reviewed the mostrecent evidence on HIV prevention needs and current resources. The report revealed that less than oneperson in five at risk of HIV had access to basic HIV prevention services globally. It also revealed that onlyone in ten people living with HIV has ever been tested for the virus. (UNAIDS,2005). Care and treatment hasbeen at the forefront of the global responses. While this increased support has been critical, greater supportand scaling up of prevention efforts should be made a top priority in the fight against HIV/AIDS. IntensifyingHIV Prevention Report (2007) stated that for every patient who initiated antiretroviral therapy in 2006,six other individuals became infected with HIV. Furthermore, as noted through the 55th WHO Regional

National Campaign Plan: Multiple Concurrent Partnerships31Committee Meeting of Health Ministers held in Maputo in August 2005, as treatment access expands, anincrease in risk behaviour could result in a net increase in HIV incidence. Unless the number of new infectionsis substantially reduced, the costs of treatment will rapidly exceed available resources. Participants in thismeeting called for expansion of access to prevention programs, otherwise treatment programs will quicklybecome overwhelmed and unsustainable.The Global HIV Prevention Working Group commissioned the Futures Institute to model the potentialtrajectory of the epidemic with and without a scaled-up prevention response. The report indicated that ifthe current trends in HIV prevention efforts continue, with slow or minimal increases in coverage over thenext decade, the annual number of new HIV infections could rise by 20% by 2012 and remain there through2015. Sixty percent of new HIV infections through 2015 are projected to occur in sub-Saharan Africa. Ifcomprehensive HIV prevention were brought to scale, however, half of the infections projected to occurby 2015 could be averted; in sub-Saharan Africa alone, 52% of projected infections could be prevented.The annual number of new HIV infections would plummet by nearly two-thirds to fewer than 2 millioninfections by 2015. In other words, scal-ing-up available HIV prevention measures would prevent 4 millionnew infections annually within the next decade. (Global HIV Prevention Working Group, 2007). Accordingto UNAIDS (2005) Intensifying Prevention Efforts Report, research shows that neither condoms alone norabstinence-only education will bring an end to the HIV epidemic, the need for multiple interventions workingsynergistically is stressed. In many developing nations, abstinence, partner-reduction, and consistent, correctuse of condoms have each played a major role in successfully reducing the number of new HIV infections.Shelton D., et al (2004) stresses the need to have a more balanced ABC approach as most interventions focuson abstinence and condoms and rarely on being faithful which includes partner reduction. Shelton D., et al(2004) calls for inclusion of messages about mutual fidelity and partner reduction in ongoing activities tochange sexual behaviour citing similar efforts as they key to reduction in adult prevalence rates in Uganda.RegionalThe Southern African Development Community (SADC) prioritized HIV prevention as a critical cornerstoneto fight HIV in Southern Africa and recognized the need to refocus and scale up current prevention effortsduring an Expert Think Tank Meeting in May 2006. High levels of multiple and concurrent sexualpartnerships by men and women with insufficient consistent, correct condom use,combined with low levels of male circumcision were identified as the key drivers of theepidemic in the sub-region . Intervention priorities that were identified during the meeting were thereduction in the number of multiple and concurrent partnerships, roll out of male circumcision, increasedmale involvement in sexual and reproductive health, increased consistent and correct condom use andcontinued programming around delayed sexual debut in the context of condom programming and reducedpartnerships. Mass media campaigns were identified as a critical tool to expose and discourage multipleconcurrent partnerships as a threat to individual and public health in collaboration with strong political,religious and community leadership.NationalThe National Strategic Framework (NSF) developed in 2000, established national priority areas to addressthe high HIV prevalence. The cornerstone of the national framework is the ‘ABC’ strategy, which stands for“Abstinence,” “Be faithful to one, uninfected, faithful sexual partner,” and use “Condoms.” The five outlined

National Campaign Plan: Multiple Concurrent Partnerships32goal areas are: (1) Prevention of HIV infection through Behaviour Change Intervention Communication(BCIC) / Information, Education, Communication (IEC), Condom Distribution, Prevention of Mother to ChildTransmission (PMTCT), Treatment of sexually transmitted infections (STIs), Vaccine Trials, HIV Counsellingand Testing (HCT), and Community Mobilisation, (2) Provision of care and support through access to AntiRetroviral Therapy (ART), Community Home Based Care (CHBC), Orphan Care and Support Groups forPeople Living with HIV/AIDS (PLWHAs), (3) Strengthened management of the national response to HIV/AIDS, (4) Psychosocial support and economic impact mitigation and (5) Provision of a strengthened legal andethical environment.A Mid Term Review (MTR) was conducted in August 2007 of the NSF to measure progress and assess futureattainment of the five key goal areas. One of the major key recommendations was the need to increase preventionefforts in Botswana. In response to the MTR, NACA developed a roadmap for expanding the preventionresponse and led the development of the “National Operational Plan for Scaling Up HIV Preventionin Botswana” to support the Government of Botswana’s goal of Zero new infections by 2016. The NationalPrevention Plan called for a National Prevention Campaign, with the first outlined strategic communicationcomponent to focus on reduction of multiple concurrent partnerships.NACA and development partners (BOTUSA, ACHAP, UN & others) in recognition of the critical cornerstoneof prevention in decreasing HIV prevalence engaged in several conversations through The UN SecretaryGeneral’s Task Force on Women, Girls and HIV/AIDS Botswana Country Report (2004), the First NationalPrevention Workshop (2005), SADC Prevention Think Tank (2006), National Strategy for Behaviour Change(2006) and finally development of the National Operational Prevention Plan (2008).The National Operational Prevention Plan outlines intervention methods to achieve significant and measurableprogress towards “Zero New Infections” as described in Vision 2016. One of the key interventions outlinedwas strategic communication to prevent sexual transmission based on understanding key determinantsof sexual transmission. The National Prevention Operational Plan calls for a high-profile BCIC campaignspecifically focusing on the acknowledged drivers of the epidemic, initially targeting multiple concurrentpartnerships. The Mid Term Review of the National Strategic Framework recommended that such a campaignfocus specifically on young people and socio-cultural constructs related to gender, sex, and sexuality, usinginnovative communication channels.

National Campaign Plan: Multiple Concurrent Partnerships33Annex 2. MCP AND HIV RISKSouthern Africa is the region in the world worst-affected by HIV/AIDS: all the highest HIV prevalence countriesare in this region. Comparison of HIV prevalence with sexual behaviour indicators made it clear thatage of sexual debut, lifetime number of sexual partners and rates of condom use could not explain the globaldistribution of HIV infections. The focus shifted to the pattern of sexual partnerships, rather than the overallnumber of sexual partners as the driver of HIV transmission. The premise that the pattern of sexual relationshipsdrives sexually transmitted infections (STIs) is not a new one, and social networks in relation to STIshave been studied for over 20 years. However, it is only in recent years that it has gained widespread credibilityand acceptance as an explanation of high HIV rates in Sub-Saharan Africa.There are two key reasons why communities where MCP is common experience wider and more rapid HIVtransmission than communities where serial monogamy is the norm: the ‘network effect’ and viremia or theacute infection phase of HIV. These factors are explained in more detail below.The Network EffectA person’s sexual network includes all the people she or he is linked with over a relatively short period oftime through sexual partnerships. This includes his or her own sexual partners, their sexual partners, theirpartners’ sexual partners, and so on. The more men and women in a society have more than one partner, themore people in the network become linked to each other. Conversely, the more men and women in a societyhave only one partner at a time, the fewer people in the network are linked.Figure 2-1 Dense Sexual NetworkFigure 2-2 De-linked Sexual NetworkFigures 2-1 and 2-2 above contrast two ways in which 18 individuals might be linked by their sexual networkat a particular point in time. In Figure 2-1, although half the people have only one sexual partner, all but twoof them are linked to each other; in Figure 2-2, where each person only has one partner, they are not linkedto anybody but that partner.

National Campaign Plan: Multiple Concurrent Partnerships34ViremiaFigure 2-3 below depicts how the infectiousness of the HIV virus changes over time. HIV is most infectiousduring the early weeks or months after infection, known as the acute infection phase, peaking at around 3weeks after a person becomes infected. During the acute infection phase a person cannot know that theyhave been infected, because it is too early for the virus to be detected by and HIV test. After a few weeks, theinfectiousness of the virus drops off sharply and dramatically, remaining low throughout the asymptomaticinfection phase, and rising again when a person’s CD4 count falls off and they develop AIDS.Figure 2-3 Stages of HIV infection1The Network Effect, Acute Infection and HIV TransmissionIt is the combination of acute infection and linked or denser sexual networks that makes MCP a riskypractice. Figure 2-4 below shows how these factors combine to facilitate the rapid spread of HIV once itenters a network.Figure 2-4 shows how, when HIV enters a dense sexual network such as this one, it can spread rapidly becausethose that become infected have sex with another person during the acute infection phase.Figure 2-5 below contrasts the spread of HIV through a sexual network characterised by MCP with thespread of HIV in a network where each individual has only one sexual partner at a time. This is often called‘serial monogamy’ and is characteristic of patters of sexual partners in the Americas and Europe.In Figure 2-5, HIV is unable to spread through the network because there are no enabling links. It is alsoimportant to note that, although there is partner exchange within the network, new sexual partnerships beginafter the acute infection period is over and are thus less likely to result in additional HIV infections.

National Campaign Plan: Multiple Concurrent Partnerships35Figure 2-4 HIV Transmission in a Dense Sexual Network

National Campaign Plan: Multiple Concurrent Partnerships36Figure 2-5 HIV Transmission in a De-Linked Sexual Network

National Campaign Plan: Multiple Concurrent Partnerships37Annex 3. ESTIMATES OF MCP IN BOTSWANAHow Many People are Engaged in MCP?It is difficult to quantify the extent of MCP in Botswana with certainty: different quantitative studies indifferent years and with different populations have yielded a range of estimates. From the quantitativestudies, it may be inferred that between one in five and one in three people self-report that they areengaged in MCP, and that the proportion is higher among men than women. However, levels of self-reportedengagement in MCP differ from qualitative perspectives that much larger numbers of people have multipleconcurrent partners.It is important to complement quantitative, self-reported measures of MCP with more qualitative perceptionsof what is really happening in society. During key informants interviews conducted as part of the NationalMCP Campaign Plan development and consultation process:The most common identified sexual relationship was multiple partnersInvestigated further, people felt that multiple partners existed equally among men and women as wellas equally among youth and older people.One informant said that, “In the past, it was the wealthy who had small houses to help other people.Nowadays, even those who are not wealthy are doing it”.Most people felt that all people in their community had multiple partners or small houses.Monogamy was not seen as a common practice among partners, although faith based organizationsand those involved in churches stated that monogamy does occur sometimes within marriages.Estimates of MCP from the key available quantitative sources are, expectedly, lower than ‘everybody’:

National Campaign Plan: Multiple Concurrent Partnerships38Annex 4. WHO IS MORE LIKELY TO BE ENGAGED IN MCP?Males versus FemalesAs noted above, almost all estimates of MCP indicate that men are more likely to be engaged in MCP thanwomen. The Makgabaneng 2003 study found that both younger and older males were more likely than femalesto have had more than one partner in the last 12 months:The PSI 2007 study found that men were almost twice as likely to report more than one partner in the lastyear or more than one partner in any of the last 6 months, although there was no difference between theproportion of men and women reporting that they were ‘still having sex with’ two or more of their last threesexual partners.Youth versus Older PeopleThe Makgabaneng 2003 figures quoted above show that younger males were almost twice as likely to reportmore than one partner in the last 12 months than older males.The PSI 2007 survey, on the other hand, found little difference between those aged 15-24 and those aged25-34. However, younger respondents were significantly more likely to report having had any casual sexualrelationship within the last year.Rural versus Non-Rural ResidentsThe PSI 2007 survey also found no general trend of rural residents being significantly more or less likely toengage in MCP than non-rural residents. However, when considering the month and year of first sex with thelast 3 sexual partners, rural residents were shown to be significantly more likely to

National Campaign Plan: Multiple Concurrent Partnerships39have had another partner since first sex with a partner they were still having sex with at the time of thesurvey.More-Education versus Less EducationThe 2007 CIET survey found that men and women educated to secondary level were more likely to havemore than one current sexual partner than those educated to primary level or below:The PSI 2007 study did not find a general trend of those with higher levels of formal education being morelikely to engage in MCP. However, respondents educated to secondary level or above were significantly morelikely to have had more than one partner during the past month.

National Campaign Plan: Multiple Concurrent Partnerships40Annex 5. TYPES OF MCPFrom review of available literature and from key informant interviews conducted with stakeholders andimplementers during the preparation of this campaign plan, many different types of MCP emerged. Fromthe available evidence, a typology of multiple concurrent partnerships was drawn up, with variations of MCPcharacterised according to the primary function of the additional partnerships (note that the typology doesnot include the main partner in the lives of those engaged in MCP).Partnerships as an Alternative to Enforced AbstinenceThe function of these partnerships is to fulfil a basic need for sex during periods when people who want tobe sexually active would otherwise experience enforced abstinence. These typically occurWhen a person is physically separated from their primary partner for work or other reasons and eitherforms casual relationships or establishes other relationships to fill the gap. Although these partnershipscan usually be turned on and off as necessary, sometimes they continue after reunion with the primarypartner. Key informants cited physical separation as a key reason for MCP, and specifically mentionedgovernment workers posted away from their families. They mentioned loneliness, desire for sexualgratification and absence from the family environment that provides some safeguard against riskybehaviour. One key informant said, ‘When men are together in one place they tend to behave verydifferently from when there is a mixture. What they do and talk about is usually centered on women andsex’.When a primary partner is in the later stages of pregnancy and the months after childbirth, when sexwith her is not permitted by cultural norms.During a transition between partnerships, when a relationship has formally ended or is formally off butsexual relations continue until / unless one or both partners move on to a new relationshipWhen a person is unsure of relationship prognoses and maintains more than one partner to ensureback up, or protect against future enforced abstinence.In the early months and years after sexual debut, when young people embark on a series of exploratoryone-night stands and short-term flings to mark a ‘coming of age’ in their minds and before they form anyprimary partnership.Partnerships for Sexual VarietyThere is widespread, if often tacit, acceptance that, as well as needing sex, people need sexual variety. Menespecially are assumed to need more than one woman to satisfy them sexually. There is also a less widelyaccepted norm that women need to be satisfied sexually and will go outside of their main partnership if theyneed to. Received wisdoms, such as ‘small houses strengthen relationships’ and ‘man cannot live on breadalone’, support these norms.These relationships often have a compensatory function, providing benefits that are lacking in a main partnershipor relief from stress or boredom. Key informants mentioned dissatisfaction or problems, specifically sexualproblems, within marriages or primary partnerships as contributing to MCP. Small houses were identifiedas providing entertainment and respite from family life, and were said to meet men’s every desire, whethersexual or emotional.

National Campaign Plan: Multiple Concurrent Partnerships 41Sexual variety can be achieved through a number of different means, whether a person has a main, long termpartner or not: one night stands, no-strings partners, frequent partner exchange, or concurrent / overlappingshort term flings. Those with a main, long term partner also maintain one or more small houses. In the citiesof Gaborone and Francistown, small houses may be in the same city as a main partner, otherwise they aregenerally maintained in a separate location to the main partner, such as the home village or cattle post. Bothmen and women have small houses, although the practice is more prevalent among men and when womentake a small house there is often a reactive or revenge motivation (i.e. she takes a small house because hermain partner has other partners). In some cultures, and particularly in rural areas, the secondary partners maybe from the extended family and the partnerships known about at least within the family.With the exception of the last-mentioned scenario, partnerships whose main function is provision of sexualvariety can generally be terminated freely by either party. From early in people’s sexual lives, they tend to havea main partner with others having the status of sidekicks.An important sub-type of partnerships whose primary motivation is sexual variety is men who engage incross-generational relationships with younger women or girls. These men often have an age mate main partnerand / or more than one younger partner concurrently, and the relationships with the younger partners tendto be short term flings of a few weeks or months. In Gaborone there are a small number of older womeninvolved in relationships with younger men, but most cross-generational relationships are between older menand younger women. For men, relationships with younger women may be about more than sexual variety,gratification or ego, they are seen as ‘necessary’ for sexual cleansing or rejuvenation.Relationships whose function for one partner is sexual variety are often the same relationships whose functionfor the other partner is material gain (discussed below), with (in most cases) the man using his relative wealthto buy access to sexual variety.Once partnerships whose main function (for men) is sexual variety have begun, women tend to have littlesay in condom use, regardless of age disparity. If men choose to use condoms in these relationships it isprimarily for their own interest (usually pregnancy prevention) and not out of consideration for their partner.These relationships can often be classed as relationships in which condoms are usually used, but where slipupsoccur due to alcohol consumption, non-availability or simple laziness; older men are less likely to usecondoms than younger men.Partnerships for Material GainRelationships that fulfil functions related to material needs typically involve women exchanging sex for goodsand/or money, but these partnerships are explicitly not commercial sex, in the minds of either the men orthe women involved in them.What is often pejoratively termed ‘transactional sex’ is a normal and acceptable function of many sexual relationshipsin Botswana and other countries in the region. Sexual relationships are accepted as being aboutexchange and it is normal for women to assess potential partners in terms of the material benefits they canprovide. For women, material gain can be the primary function of one-night, short-, medium- or long-termpartnerships. Although there are some men who enter into sexual partnerships for financial gain (usuallywith older women), this is atypical.

National Campaign Plan: Multiple Concurrent Partnerships42Where Botswana differs from other, poorer countries in the region is in the nature of the material benefitsthat a sexual relationship serves to provide. Relationships whose function is to provide for consumerist‘needs’ are more common, and those whose function is to provide for survival needs less common than inneighbouring countries. Perceived consumerist ‘needs’ are driven by the media and peer pressure / peer envyand include non-essential clothes, transport, household goods and gadgets and nights out. The discourse usedby women to describe the function of these relationships is often one of ‘survival sex’ or need, even wherethese are actually consumerist wants; relationships may also fulfil a combination of consumerist and morebasic needs. Contrary to the dated stereotype of rich men preying on vulnerable women, women are oftenactive agents in seeking different or additional partners who can fulfil unmet needs in their life.For women engaged in concurrent partnerships, the relationships whose primary function is material gainmay supplement a main partnership that meets more emotional needs; for other women, the primary functionof each relationship may be classified as material gain. There are a number of sub-typologies of such partnerships,including: women maintained as small houses; ‘ministers’ maintained by young women; and one-nightor repeat sex for drinks, rides or gifts. While most cross-generational partnerships can be characterised astransactional, not all transactional partnerships are cross-generational.Key informants mentioned monetary and material benefits as the main motivating factor for engagementwith multiple partners, affirming that the type of benefits depend on economic status, but vary from basicneeds like food, rent and utilities to luxury items such as furniture, cell phones and clothing. Key informantscited women and their children’s dependence on men for financial support as a barrier to leaving unfaithfulpartners, and fear that financial support will be cut off as (another) barrier to challenging unfaithful men. Regardingcross-generational relationships, key informants noted that girls’ families also benefit materially fromtheir daughters’ relationships with older men and this can lead parents to turn a blind eye.The financial imbalance in these partnerships typically translates into a lack of negotiating power of when andhow (i.e. with or without a condom) for women, whether in a one-night stand, a long term relationship oranything in between. The actual or perceived compulsion to reciprocate material benefits from a relationship,and/or the desire to continue benefitting materially, leads to women involved in partnerships whose primaryfunction in their lives is material gain to have even less negotiating power over sexual matters than women inother types of relationships have.Looking for a Potential Main PartnerMen and women looking for a serious or stable relationship may get through a number of short-term partnersduring their quest. These relationships may overlap while their potential is assessed, or may only beviewed as a potential main relationship by one partner, while the other views it as a short term affair to fulfilbasic sexual needs or provide sexual variety. However, the main rationale for including this partnership typein an MCP typology is that, even where relationships do not overlap, those seeking a main partner may gothrough 2 or more short term efforts during a year and ‘more than 1 partner during the last 12 months’ isan often-used definition of concurrency. This type is different from the others listed because (at least one of)the partnership’s actual or potential function(s) in the mind of the seeker is emotional rather than sexual ormaterial.

National Campaign Plan: Multiple Concurrent Partnerships43Figure 5-1 below shows the main types of MCP in Botswana.Figure 5-1 Typology of MCPMain function of extrarelationshipsAvoidingenforcedabstinenceSexual varietyMaterial gainPotentialprimarypartnerPhysicalseparationOne nightstandsConsumeristwantsPregnancy /childbirthbreakNo-stringspartnersSurvivalsexTypes of MCPTransitionbetweenpartnersSidekicksOne-offsSparewheel[having]Small houses[being]Small housesComing of age[having]Ma 14[being]Ma 14

National Campaign Plan: Multiple Concurrent Partnerships44Annex 6. LENGTH OF PARTNERSHIPSMCP is characterised by short-term partnerships. Of all the last 3 sexual partnerships reported by respondentsaged 15-34 in the PSI 2007 study, 23% had begun during the last three months and 69% of these lessthan one month ago. As Figure 6-1 below shows, those engaged in MCP have more short-term partnershipsand few long term partnerships:Figure 6-1 MCP and months since first sexwith current partners, men and women aged15-34, PSI 2007*Had >1 partner in same month during last 6 months or still having sex with >1 oflast 3 partners at time of survey. PSI 2007The PSI 2007 study found that in general, sexual partnerships were strikingly short, with men reporting morepartners with whom they had first had sex more recently than women (Figure 6-2 below). This pattern ofreporting hints at frequent partner exchange and under-reporting of total partner numbers per year by bothgenders.Figure 6-2 Months since firstsex with last 1-3 partners,men and women aged 15-34,PSI 2007

National Campaign Plan: Multiple Concurrent Partnerships45The PSI study also confirmed that those engaged in MCP had more short term casual partnerships and fewer2long term marital or cohabiting partnerships. Figure 6-3 below shows the distribution of ongoing partnershipsby type and duration:Figure 6-3 Months since first sex with last 1-3 partners with whom respondent was still having sex at time of survey,by partner type and MCP, men and women aged 15-34, PSI 2007

National Campaign Plan: Multiple Concurrent Partnerships46Annex 7. SOCIETAL DRIVERS OF MCPSocietal Barriers to MCPIt is important to preface any discussion of societal factors that drive MCP with recognition of the many positivesocietal forces that inhibit multiple partnerships. Moral behaviour is very important to the great majorityof Batswana and promiscuity is highly disapproved of. The fact that most secondary or casual partnershipsare secret points to the social unacceptability of MCP and the fear about shame, censure and loss of statusthat might result from being known to have multiple sexual partners. For those who are married, taking otherpartners not only constitutes infidelity to one’s spouse but also breaking one’s commitments before God.Customary courts can punish married people who are unfaithful to their spouses. The extended family andfaith communities play important roles in the lives of Batswana men and women, and both these institutionsencourage abstinence and fidelity as moral behaviours, not merely HIV prevention strategies. Respect forelders and leaders, who also play a key role in encouraging moral behaviour, remains strong. Moral educationof young people is important in Botswana’s cultural traditions and can be seen in the bogwera and bojaleceremonies that mark the transition to adulthood: these initiations include teaching young men and womenabout correct sexual behaviour, including fidelity.However, these positive forces are undermined by other factors which drive men and women to go againsttraditions of moral behaviour and engage in MCP. These drivers of MCP are discussed below.Taboos about Sex in Public and Private SpheresIn every arena, from the media, to the kgotla meeting, to the church group , to the school, to the family, tothe couple, taboos prevent the discussion of issues related to sex. In public media and community settings,discussion about HIV/AIDS avoids discussion of difficult issues relating to sexual behaviour and the societalfactors underlying sexual behaviour that have and are still contributing to HIV transmission.Within the family, there is rarely any parent-child communication about sexuality and relationships. Parentsfeel unable to talk to their adolescents about sexuality and growing up: most believe they are protecting theirchildren by not exposing them to these subjects; the few who would like to talk to their children do not knowhow or where to start. This means that many young people only learn about sex and relationships once theybecome sexually active and go into their first sexual and relationship experiences unequipped to deal withthem. Young people introducing serious boy- or girl-friends to their family is almost unheard of, which meansthat from their first relationships they learn how to keep them secret from those closest to them, unlessthey are ‘in on’ the deception. These taboos are acted out in the private sphere but reinforced by subjectivenorms within communities.Between couples, discussion of issues or problems related to sex and relationships rarely occurs. The inabilityto communicate and resolve problems with a primary partner is a key reason why men seek sexual satisfactionelsewhere, often prompting women to seek another partner for revenge. Some men would not eventhink of discussing such issues with their partner, rather feeling that they are doing the right thing by stayingwith them even though they are not sexually satisfied. Other men would like to be able to resolve problemswith a primary partner but do not know where to start. Furthermore, men feel as though they should beexperts on matters relating to sex and are afraid to appear not to be. For some women, discomfort in raisingissues about sex and relationships is linked to a fear of challenging men and fear of being abused, beaten orabandoned.

National Campaign Plan: Multiple Concurrent Partnerships47Lack of Parental SupportAIDS has deprived many young people of parents and as they deal with the challenges of adolescence, youthand young adulthood they lack the support and help that they need to make safe, responsible judgements andchoices in their lives. Without this support, they are more susceptible to negative or even harmful influencesfrom peers and adults because they lack the balancing, positive influences of the parental home and if theyfind themselves in trouble or danger they may have nowhere to turn for help.A large proportion of the current generation of young adults has been brought up by single mothers, whothey have often seen treated badly by a succession of men. Young men and women have therefore neithergrown up with positive male role models, nor with second-hand experience of long-term, loving, committedand mutually supportive relationships. In their own sexual lives and relationships, it is unsurprising thatmen adopt the behaviours they learned when they were boys from watching the men in their mothers’ lives,and that women resolve not to suffer the way their mothers did but to use men in ways that benefit them.However, a very positive generational shift in values that has resulted from the bond between boys and theirsingle mothers is changing in young men’s attitudes to their children, compared to their fathers’ generation.Whereas many of the last generation of fathers had little involvement in their children’s lives if they did notstay with the baby’s mother, today’s young men are devoted to their children and actively engaged in theirlives.Discussion of sexuality and relationships between parents and their children is taboo, with parents avoidingany conversation relating to sex for fear of encouraging children to become sexually active or promiscuous.Thus young people begin their sexual lives with little idea about what healthy sexual relationships really areand take their cue from the behaviours they see around them and the partnerships they fall into. They cannotintroduce boy- and girlfriends to their parents because parents are afraid to be seen to be condoning sex. Thisdesire on the part of parents to protect their children has the unintended effect of teaching young people,from their first relationships that may not even involve sex, how to keep relationships a secret. This behaviouris then perpetuated as they grow up and move through the MCP life cycle of sugar daddies or mummies,sidekicks, small houses and eventually Ma-14. Even as adults, men and women cannot introduce their primarypartners to their parents unless they are engaged or married, and so this potential source of support for andprotection of primary partnerships is lost.Status of WomenAlthough Batswana women are more empowered than ever before in terms of education, employment andparticipation in public life, Botswana remains a gender-unequal society. Even in the public sphere, men earn,on average, three times more than women, and under customary law women do not have the same status asmen.

National Campaign Plan: Multiple Concurrent Partnerships48In the private sphere, women have gained much less ground as Botswana has modernised. Violence and raperemain common, with 60% of women reporting domestic abuse and a 50% increase in reported rape between1995 and 2007. In the home, men have been slow to cede the ground that has been granted to women by theGovernment in public life, education and employment.Qualitative research consistently reveals that men still make all decisions about sex (including when it happensand whether condoms are used), even in younger couples and casual relationships, and women are ‘notallowed’ or afraid to challenge men’s decisions and behaviour.Gender roles within relationships remain traditional: men providing materially and protecting the family;women bearing children and having a duty to provide sex on demand. Expectations of sexual fidelity aredeeply unequal. A woman is not allowed to ask a man where he has been or who with, or challenge him whenshe knows he has other partners, but a man expects his partner to be faithful to him; for the woman, thisexpectation is often backed up by a fear of violence.For younger and poorer women, all of these inequalities are magnified. Traditionally the young obey the oldwithout questioning. The greater a woman’s (and her family’s) inability to survive financially without the manor men she has sex with, the more control he has or they have over her behaviour.It is unsurprising that women who seek greater control and equality in their relationships with men do itwithin these constraints: by using men for material gain, accepting that they are not the only partner andhaving multiple partners themselves.Mobility and Physical SeparationTraditions and infrastructure that make it easy to maintain multiple bases, as well as an employment culturethat posts men and women away from their families, also facilitate MCP. There is a strong tradition of thosewho move away from home maintaining regular links with their home village and cattle post, with distinctidentities (and partners) associated with each base. Travel between these and other bases is facilitated by thecountry’s excellent road and communications infrastructure and growing car ownership.Many Batswana are employed in sectors or industries that post them away from home for long periods.Nineteen percent of BAIS II respondents had spent more than 30 days away from home in one stretch, butGovernment and tourism workers are posted for longer and may only return to their families a couple oftimes per year. Key informants consulted during the campaign development process frequently mentionedgovernment workers who were separated from their families as contributors to MCP. During separation,they experience loneliness and desire for sexual gratification and are away from the family environment thatprovides some safeguard against risky behaviour. As one key informant said, ‘When men are together in oneplace they tend to behave very differently from when there is a mixture. What they do and talk about isusually centred on women and sex’.Relationship NormsNorms about long-term, emotionally committed relationships have been absent from the lives of many oftoday’s youth and young adults. Less than 15-20% of adults are married and many of today’s 18-35 generationwere raised by single mothers. They are reluctant to marry, often citing the high cost of getting married as areason.

National Campaign Plan: Multiple Concurrent Partnerships49Cohabitation is a common living arrangement but cohabitation does not constitute recognized commitmentsor obligations to the other party, including sexual exclusivity or fidelity. There are no legal or familial repercussionsof infidelity to a cohabiting partner as there are in marriage.Traditional polygamy, in which a man has more than one wife, is still practiced in some cultures withinBotswana and still influences mainstream perceptions about the normality of men having more than onepartner. There is a key distinction to be made between polygamy as traditionally practiced, where all of aman’s wives were known to the community and he was expected not to stray elsewhere, and today’s multipleconcurrent partnerships which polygamy is envoked to justify. It seems that the concepts of polygamy andmultiple partnerships have become blurred in people’s minds. While it is true that in the past a man’s statuswas linked to his ability to provide for many wives, today that status is simply about having sex with manywomen, women who are kept secret other than from the male peers with whom they give him prestige.Key informants also spoke about the way in which the foreign media creates additional negative norms aboutrelationships by showing how people can have multiple concurrent partnerships with minimal consequences.Younger people are particularly susceptible to trying to copy what they see in the movies and soapies.Economic DriversBotswana has experienced rapid economic change and growth since independence, indeed it was the fourthfastest growing economy in the world from 1975-2005. Today Batswana have access to a vast range of materialgoods that are widely available in stores and prominently advertised in the media. Western media showsfurther expand the range of material goods to which viewers can aspire.Economic growth has not benefited everyone equally but have been accompanied by a rapid increase in inequality.Today in Botswana, the gap between rich and poor is one of widest in the world: the income of therichest 10% of the population is 43 times higher than that of the poorest 10%. On the: Gini index of incomeequality, (on a scale between 0 and 100), Botswana rates Botswana 60.5, close to the most unequal countriesNamibia (74.2) and Sierra Leone (62.9) (the most equal countries are : Denmark at 24.7 and Japan at 24.9).Economic growth and opportunity, and widening wealth disparity have led to a rapidly pervasive culture ofmaterialism and routine interaction between individuals with very different socio-economic status. For thosewith greater wealth, it gives them access to sexual partners, for whom sex becomes a commodity that theycan trade for what they need or want but cannot afford. The ease with which people can obtain credit tofund purchase of ‘status’ items, such as cars, in order to create an illusion of wealth, exacerbates the problem.Many key informants cited monetary and material benefits as the main motivating factor for engagement withmultiple partners.As noted above, women are less economically advantaged than men and key informants also cited women’s(and their children’s) financial dependence on men as a barrier to leaving or challenging unfaithful partners,because they would lose out if the partner cut off financial support, that varies from basic needs like food andrent to luxury items such as furniture, cell phones and clothing.The gap between rich and poor is also a driver of two distinct types of cross-generational relationships: youngadults who consciously and willingly trade sex for material goods; but also, particularly in rural areas, youngergirls who are lured by older men with gifts and then ‘have to’ reciprocate with sex.

National Campaign Plan: Multiple Concurrent Partnerships50The girls themselves get used to having things they cannot afford and to the men who provide them. However,their families often also benefit materially from their relationships with older men and turn a blind eye. Onekey informant said that they had ‘seen a set up where parents put a girl‘s room where it will be deliberatelyaccessible to the man who may visit her’.AlcoholA majority of those consulted during the campaign development process cited alcohol as one of the majorreasons for high HIV prevalence in their communities.The effects of impaired judgment in sexual behaviour due to alcohol are well documented. A 2006 study on3alcohol and high risk sexual behaviours in Botswana (Weiser) found that for both men and women heavierdrinking was associated with higher odds of all risk behaviours: unprotected sex, multiple partners, and payingfor (men) or selling/trading (women) sex. The more people reported drinking, the more likely they were toreport risky behaviour. The same study found that 31% of men and 17% of women met the criteria for heavyor problem drinking and that 39% of men and 20% of women reported drinking alcohol before sex in thepast year on a regular or semi-regular basis. This is in contrast to BAIS II which found that 10-20% of peoplereported drinking prior to last sex; however, analysis of BAIS II data on alcohol and sexual behaviour alsoshows that alcohol is associated with risk behaviours.The Weiser study found that:For both genders, heavy drinkers were more likely to report unprotected sex than problem drinkers,who in turn were more likely to report unprotected sex than to moderate drinkers, and people whoconsumed no alcohol least likely to report unprotected sex;Compared to non-drinkers, moderate male drinkers were nearly three times as likely to have paid sexwith money or other resources, and heavy or problem drinkers were approximately four to five timesmore likely.Women who were problem or heavy drinkers had over eight times the odds of providing sex in exchange for money or resources compared to non-drinkers.Intergenerational sex was also strongly associated in the Weiser study with heavy drinking for bothmen and women, and previous qualitative studies have shown that intergenerational and transactionalsexual relationships are often initiated in drinking establishments.

National Campaign Plan: Multiple Concurrent Partnerships51Annex 8. INDIVIDUAL DRIVERS OF MCPThe analysis of individual behavioural drivers below is based on the 2007 PSI study of determinants ofpreventive behaviours against HIV among 15-34 year olds nationally (except for Ghanzi and Selibe-Phikwedistricts).Segmentation analyses were used to identify significant statistical correlations between MCP behavioural indicatorsand potential behavioural determinants. There was a significant and positive correlation between thefollowing behavioural drivers and one or more of the target partner reduction behaviours:Men and women were significantly less likely to be engaged in MCP if they:Knew overlapping sexual relationships are more risky;Felt stronger encouragement from friends to have only one sexual partner; orBelieved more strongly in their ability to resist temptation to have other partners.Men were significantly less likely to be engaged in MCP if they:Believed less strongly in the benefits of having multiple partners: choosing among them, ease of movingon, peer prestige, sexual satisfaction, not sleeping alone;Believed less strongly that having multiple partners is no problem if condoms are used;Believe less strongly that sex does not require or signify love or emotional commitment.Women were significantly less likely to be engaged in MCP if they:Were more strongly influenced by social norms disapproving of multiple partners;Were less likely to report drinking to excess or to gain confidence;Felt that they had more power to decide when they had sex.Responses to questions covering many different potential behavioural determinants analysed for significantcorrelation with engagement in MCP. Those not listed in the table above were not found to have any significantcorrelation with the behavioural indicators. The factors analyzed were:Social norms about discussing HIVPositive and negative social norms about number of sexual partnersNorms about transactional sexKnowledge that overlapping sexual relationships are more risky

National Campaign Plan: Multiple Concurrent Partnerships52Factors related to alcoholAbility to resist temptation to have different partnersPeer social support for reducing partnersPeer pressure to have multiple partnersSusceptibility to HIVAttitudes to multiple partners, condoms and HIVLocus of control over HIV infection and sexBeliefs about the benefits of having multiple partnersAttitudes about sex, variety and emotional commitmentPositive and negative expectations about having multiple partnersSubjective norms about reducing partnersDemographic factors including age, gender, residence, education, employment and circumcision (malesonly)The behavioural indicators analysed were:Had more than 1 partner in last 12 monthsHad more than 1 partner in the same month during any of the past 6 months or still having sex withmore than 1 of last 3 partners at time of surveyStill having sex with more than 1 of last 3 partners at time of surveyHad any casual partners in last 12 monthsStatistical Analyses from PSI 2007 StudyThe tables below show how the above behavioural drivers correlate positively and significantly with each ofthe target behaviours for specific population segments. The target populations (specified at the top left-handcell of each table) is divided into two segments: those who are engaged in MCP and those who are not engagedin MCP, according to the behavioural definition stated in the top left-hand cell of the table. All the potentialbehavioural determinants listed above were analysed for significant correlation with the behaviour; thefactors not listed in the tables below had no statistically significant correlation with the target behaviours.Key:Mean score: the means listed reflect the mean score out of 5, where 1 is the least favourable response (strong agreement with anegative statement or strong disagreement with a positive statement) and 5 is the most favourable response (strong disagreementwith a negative statement or strong agreement with a positive statement).R denotes individual or multiple items that were negative in their original formulation and have been reverse coded so that 1 isthe least positive response and 5 the most positive response.† denotes indicators constructed from multi-item scales. For these indicators, the mean scores shown are for a number of similarstatements that measure the same concept.Sig (significance) = *** p< 0.001, ** p

National Campaign Plan: Multiple Concurrent Partnerships53

National Campaign Plan: Multiple Concurrent Partnerships54

National Campaign Plan: Multiple Concurrent Partnerships551. Wawer et al, ‘Rates of HIV-1 Transmission per Coital Act, by stage of HIV-1 Infection, in Rakai, Uganda’,The Journal of Infectious Diseases 2005: 191: 1403-14092. The classification of partner type (marital / cohabiting, other regular, and casual) in the PSI study allowsroom for different respondent interpretations of ‘casual’ and ‘regular and also does not take account of thefact that cohabitation and marriage carry very different expectations of commitment and fidelity.3. Weiser et al, ‘A Population-Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana’, 2006