Cultural obstacles to abstinence and being faithful present challenges for PEPFAR HIV programmes

Certain cultural factors in resource limited settings pose significant challenges to prevention efforts and must be addressed to make it possible for people (especially youth) to adopt behaviours such as abstinence, being faithful, and correct and consistent condom use (ABC) according to several presentations at the 2006 PEPFAR Implementer’s Meeting held mid-June in Durban, South Africa.

Some PEPFAR-funded prevention programmes are attempting to change cultural norms around polygamy, cross-generational sex, male attitudes towards women, sexual coercion and violence, taboos surrounding discussing sex, economic pressures and social expectations to have sex. Failure to confront these challenges could lead to the failure of prevention programmes, and could also have extremely negative unintended consequences — including, potentially, the rape of girls known to be abstinent.

This issue was addressed during both plenary talks on prevention.

“When communities set expectations about the sexual behaviour of young people, they must also create an environment where that behaviour is possible,” said David Stanton, a clinical epidemiologist at USAID.

“Although the ABC approach is an important strategy, there are a number of challenges to this approach,” said Dr Dorothy Mbori-Ngacha of CDC Kenya. “The reality is that for many women, these strategies are hard to implement, and fail to offer real options that [fit] into their daily reality.”

“For example, abstinence is meaningless when women and girls feel they must resort to sex as a matter of survival, or when sexual activity is coerced.

“Likewise, being faithful is an effective strategy, only if both partners are faithful and none of them is infected. Condoms, though effective, are a male decision, with women having very little power to negotiate their use due to their dependency on their male partners.”

“And finally, most women have limited access to female controlled methods that will enable them to control their own sexual health. We therefore need to recognise these limitations and make sure that our prevention programmes use the ABC approach as a platform to incorporate other prevention strategies.”

Barriers to the ABC strategy in Nakuru, Kenya

In a survey of adults and youth conducted by Horizons/Population Counsel and Family Health International in Nakuru Kenya, a number of barriers to ABC were identified.

“There are mixed, conflicting, and inaccurate messages on the ABCs from community as well as institutions;” said Naomi Ruttenberg of Horisons, “There was a perceived inability to control sexual behaviour, especially for men: that simply it wasn’t feasible, that biological urges were going to overcome any sort of self-control; and [gender-related] structural factors: the barriers around gender-based violence and women’s lack of power. No matter how well intended in their resolve [to negotiate safe sexual behaviour], they simply lack to power in relationships to act on it.”

“There were some responses about the negative perceived physical effects of abstinence and being faithful — that regular sexual activity with a number of partners was a natural healthy thing to do and that restraining it was unhealthy. There were also negative views about condoms and a sense of fatalism about becoming HIV infected despite adopting safer sexual behaviour.”

Ruttenberg noted that the community had conflicting views about those who are abstinent. One participant said that “the community thinks that you are abnormal,” while a male youth said “the community regards one as holy and a role model.”

Involving parents

“The cultural situation in many of our countries is such that parents are not usually the ones to discuss sex with their child, but programmes in Uganda and Kenya are challenging that norm,” said Dr. Thomas Kenyon of the CDC in Namibia at the close of the conference.

Indeed, discussions of sex between children and parents is virtually taboo in some countries — and may not entirely be helpful. In Uganda, a programme called “Straight Talk” documented the lack of parental comfort discussing sex and their knowledge around sexual behaviour. For example, 65% of parents did not want their children to come to them with questions about sex. Worse, they held sexist notions that could undermine prevention efforts. According to Karusa Kiragu of the Population Council, “65% of parents agreed with the statement ‘women should tolerate abuse to keep families together.’ ” Many adult men and women felt men who had multiple partners were more powerful and encouraged male risk-taking.

According to Kiragu “programmes are urgently needed to help parents deconstruct these attitudes... and to increase parental confidence discussing sexual matters.”

Such a programme is now being piloted in Kenya based on a 2001 needs assessment among youth in Nyanza province in which, “young people highlighted the lack of communication about sex-related issues between adults and adolescents as an important obstacle to effective HIV prevention,” said Fredrick Onyango of the CDC in Kenya. Working in Asembo, a rural Nyanza community, the community embraced the idea of a parent-centred approach to youth HIV prevention.

They selected an intervention called “Parents Matter” from the US, which tries to foster better communication around sex between parents and children between 8 and 12 years of age. This model underwent substantial adaptation, working closely with the community to be relevant in this cultural context, and eventually became “Families Matter.” Although it is too soon to see whether the intervention has had an impact on HIV transmission or sexual risk taking among children, there have been statistically significant improved scores in parent-child communication on sexual matters (in both children and parents). “Parents reported being very positive about Families Matter,” said Onyango.

Polygamy and multiple sex partners

A couple of talks, including Stanton’s highlighted the danger of having multiple sex partners or polygamy which is a common practice in many sub-Saharan countries. Some US funded efforts are specifically trying to address this, according to Dr. Mark Dybul, who is the acting US Global AIDS Coordinator. “For example, in Zimbabwe we worked very close with a church that had for many years endorsed polygamy and we worked with that church to explain the HIV risk associated with polygamy and multiple partnerships and in fact as a result of our and many other people’s work with that church in the last 8 months, they reversed their position and are in fact teaching now against polygamy.”

Likewise, another PEPFAR funded effort appears to be reducing the number of concurrent partnership among long distance truck drivers in East Africa .

Intergenerational sex

One benefit of involving parents (in particular the men) is that they may begin to adopt more protective attitudes towards young women in their cultures, in general, and could potentially reduce the incidence of intergenerational sex, which both Dr. Mbori-Ngacha and Stanton noted is a major problem for prevention programmes. For example, “quite a few women in South Africa have sex partners who are five or more years older than themselves and the result of those partnerships is a much higher prevalence among young men and women who have sexual partners older than themselves,” noted Stanton.

In fact, according to one mathematical model presented at the meeting, ending this practice would have a dramatic impact on the epidemic. But opinions vary about how best to do this, whether by empowering young women to avoid casual sexual partnerships with older men who are part of high risk sexual networks or by getting older men to stop predating young women.

Empowering the girls or changing the men?

Not everyone was convinced that the latter approach would work, however. Even the two plenary speakers on prevention had slightly different takes on whether to focus on empowering girls or getting the men to change.

In order for prevention programmes to be truly effective, they need to address “the special vulnerability of women,” according to Dr. Mbori-Ngacha. “Collectively we need to ensure that young women most at risk have access to information on HIV prevention. In addition, we need to build the self-esteem of young women and equip them with practical skills such as refusal and negotiation skills to enable them to take control of their lives and refuse sex until they are mature enough to engage in safe sex.”

But “for prevention programmes to be successful we also need to target men,” she added.

Stanton directed his attention solely to the men. “When young people, mostly young women, aren’t able to abstain when they want to, this is probably not the failure of an abstinence programme. Instead, it is more likely a failure, and sometimes the complete absence of programmes promoting fidelity, partner reduction and sexual responsibility among men,” said Stanton. “I think also the `be faithful` message must be given to the men in the community, so that the younger people can actually achieve the message of A & B.”

Programmes targeted towards men are needed to discourage intergenerational sex, multiple partnerships and to encourage fidelity to their partner, as well as to use condoms if they do have risky sex. And some evidence provided at the meeting suggested that male involvement can indeed work, and that behaviour change is possible over time especially following peer-based interventions.

For example, a study in Brazil investigated whether it would be possible to encourage young men to treat young women as equals. The study enrolled three groups with a total of 780 men from low-income communities between the ages of 15-24. One group received group education sessions led by slightly older peers, another group received the group education combined with a community-based education behaviour change campaign, and the third group served as a control.

At baseline, about 25% had had symptoms of a sexually transmitted infection within the previous 3 months, and almost 40% had had multiple sexual partners in the past month. After a year of follow-up, statistically significant positive behavioural changes occurred in both intervention groups in attitudes towards gender norms and equitable relationships, plus the young men were more likely to use condoms and developed fewer STIs. A trend towards a greater effect was observed in the combined intervention group.

The consequences of not addressing the sexual coercion of women

Of course, neither approach is mutually exclusive but if men do not change, then, in some cultures, prevention programmes could inadvertently put the lives of young women at risk, according to a survey of young people in South Africa.

“Sexual coercion and rape were frequently cited as barriers to abstinence for girls and women, especially by girls,” said Tobey Nelson of Horizons and the International Center for Research on Women. According to Nelson, one girl in a focus group discussion said: “If a girl abstains and boys know that, they then want to rape that girl because they know that she does not have AIDS. The bad thing is that they want to kill the girl after the rape.”