1. Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania Suzanne Maman Health Behavior and Health Education

2. The associations between HIV and violence Violence as a risk factor for HIV infection (1)Women in violent relationships less able to enforce HIV preventive behaviors. (2)Women who have experienced physical and sexual abuse engage in more HIV risk behaviors. (3)Biological trauma from forced sex may facilitate HIV transmission. Violence as an outcome of HIV status disclosure (4) Violence is a major barrier to disclosure for HIV+ women.

3. Growing evidence of the overlapping epidemics of HIV and violence In South Africa, women with violent partners have a more than 50% increased risk of acquiring HIV. (Dunkle et al., 2004) In Tanzania, the odds of reporting violence are 10 times higher for young, HIV-positive women as compared to young, HIV-negative women. (Maman et al., 2002).

4. Rationale for working with young men Men are generally perpetrators of gender-based violence Men control the terms & conditions of sexual relationships Very little is understood about the attitudes and behaviors of young men in this context Young men lack access to information and services Adolescence is a time when lifelong patterns are formed

5. Tuelemishane Project Dar es Salaam, Tanzania An intervention to reduce HIV risk and reported use of violence among young men using a combination of peer support and community theatre

6. Tanzania Population: 33 million Pop in Dar: ~ 3million Per capita GNP: $246 Life expectancy: 45 years HIV prevalence: 8.8%

7. Intervention Design The intervention consists of two major components: Community Theatre Trained theatre group perform interactive skits Performances in venues frequented by young men 3 different skits performed 12 times Peer support Young men enrolled in groups of 10-12 Groups meet monthly for 12- months Facilitated by trained peer group leaders

8. Research Design Intervention 475 men, 16-24 yrs Interviewed baseline Participate in intervention Interviewed 2 month Post-intervention Control 475 men, 16-24 yrs Interviewed baseline Interviewed 2-month Post intervention IDIs with the female partners of 40 men Formative Phase 60IDI 14 FGD Evaluation Design

9. Formative and Baseline Findings

10. Relationships revolve around sexual activity To love a partner means one must be willing to have sex “How can she be my partner without making love? To know that she loves you and she’s your partner you must make love, that’s why I convinced her. “ (male, 24 years, not married) There were few examples of partnerships between young men and women that did not involve sex.

11. Mistrust of sexual partners due to concerns of infidelity Youth described little emotional/romantic love Mistrust stemmed from concerns about infidelity and financial motives Infidelity openly acknowledged by men and some women Infidelity the most common trigger for violence mentioned by women

12. Mistrust also related to the transactional nature of relationships Expectations of money/ gifts from male partners Money/gifts used as yardstick to measure the degree of men’s love. Some women engaged in sexual relationships out of need “ When girls need assistance they must have sex to get that assistance.” (male, FGD participant) Concerns over the financial motivations of women was the primary trigger for violence mentioned by men.

13. The language that youth use to describe their relationships reflect the mistrust Pulling the load (Anavuta mzigo) –Men describe taking on new girlfriends as pulling the load Skinning the goat (Kuchuna buzi) –Women describe strategies to extract money from their partners as skinning the goat

14. Conservative attitudes regarding gender norms and expectations 69% of men agreed that men should have final say in all family matters 48% felt women should tolerate being beaten to keep family together 44% felt if women want to leave abusive partner they must leave children behind

15. Experiences with violence in childhood were common 11% reported unwanted sexual touching or intercourse under the age of 12 years 43% reported experiencing serious physical violence as a child 28% reported witnessing their father physically assault their mother

16. Young men describe substantial HIV risk 70% of men were sexually active and the mean age of first sex was 16 years (SD 2.90 years) The mean number of lifetime partners was 3.96 (SD 5.55) 47% reported having had sex without a condom in the past 6 months

17. Use of physical violence against female partners was high Among sexually active men, 30% reported at least one episode of physical violence with a partner 9% reported using physical violence to force a partner to have sex 5% reported reacting violently when a partner refused to have sex

18. Factors associated with the use of physical violence Number of sexual partners –Men with 4-10 lifetime partners had 5 X greater odds of reporting violence (95% CI: 2.6-10.4) –Men with 2 or more partners in the past 6-months had 2 X greater odds of reporting violence (95% CI: 1.19-4.56) Pressure from peers to have sex –The odds of reporting violence was 2.5 X higher among men who report moderate pressure from peers to have sex (95% CI: 1.30-4.99) Childhood physical abuse –The odds of reporting violence was 2 X greater for men who experienced physical violence in childhood (95% CI: 1.42-3.33)

19. Conclusions

20. Despite being two decades into epidemic, youth are still at risk 8.8% of Tanzanians are HIV infected nationally 60% new infections occur among 16-24 yr olds Multiple partnerships were common Unprotected sexual intercourse was common

21. Men control the sexual decision making in relationships Men describe conservative attitudes related to sexual norms and expectations Women have limited agency in the process of initiating and maintaining partnerships

22. The socioeconomic context plays a role in the formation and dynamics of sexual relationships –Women engage in sexual relationships to achieve financial support –The transactional nature of relationships leave women vulnerable to both HIV risk and violence

23. There were clear associations between HIV and violence Men with more sexual partners report using violence more often Infidelity was the trigger for violence mentioned most often by women

24. Tuelemishane Project Moves us out of the clinic into the community, and shifts the focus from women to men Designed to give men space to talk about norms surrounding sexual behavior and conflict. Through a 1-year intervention we hope to see some changes in attitudes and norms—and optimistically behaviors.

25. Where do we go from here? One approach is not sufficient –Multi-level interventions are needed The challenge is to reach men where they spend time & to keep them engaged –Venue-based interventions Younger men need to be the focus of our interventions

26. Acknowledgements Funding: The intervention is funded through a grant from USAID, Interagency Gender working group. The research is funded by The Population Council Horizons Project. Co-Investigators J. Mbwambo, (Muhimbili); M. Sweat, H.Lary (JHU), M. Roche (UNC); F. Kouyoumdjian (Toronto) Research Staff: R. Kaballa, A. Mwampashi, L. Sabuni, E. Kakwezi, U. Peter, L. Ezekiel, E. Chezi, H. Marijani and J. Donath.