1. Multiple and Concurrent Partners: New Insights, New Tools and New Challenges Allison Herling Ruark, MSPH Harvard Center for Population and Development Studies allison_herling@harvard.edu Christian Connections for International Health Conference May 24, 2009

2. Presentation Outline 1.Epi evidence for importance of addressing Multiple and Concurrent Partnerships (MCP) 2.Recent research meetings on MCP 3.Program guidance from Harvard APRP/UNAIDS/World Bank meeting (Gaborone, Botswana, Jan 2009) 4.Resources available for MCP programming and M&E

3. 1. Epi evidence for MCP Especially in hyper-epidemics of Southern Africa, concurrent partnerships may be a key driver of HIV transmission Concurrency vs. serial monogamy “Typical” pattern of concurrency is relatively small numbers of sexual relationships that are ongoing in time and overlap

4. A note about the term MCP MCP = Multiple Concurrent Multiple and Concurrent Partnerships

5. 2. Recent meetings on MCP Southern African Development Commission (SADC) Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa Maseru, Lesotho, May 2006 identified high levels of multiple and concurrent partnerships by men and women with low consistent condom use, and in the context of low levels of male circumcision as the key drivers of the epidemic in southern Africa

6. 2. Recent meetings on MCP (cont.) UNAIDS Regional Support Team for Eastern and Southern Africa and the Soul City Institute: Multiple Concurrent Partnerships: Campaigns and Communications: Towards a Coordinated Regional Response Johannesburg, Sept 2008 focused on communication strategies for addressing MCP (e.g. Soul City’s OneLove campaign)

7. 2. Recent meetings on MCP (cont.) PEPFAR technical consultation on MCP: Addressing Multiple and Concurrent Sexual Partnerships in Generalized Epidemics Washington, DC, Oct 2008 a number of excellent technical presentations (PPTs) available on website (see handout for URL)

8. 2. Recent meetings on MCP (cont.) UNAIDS Monitoring and Evaluation Reference Group Nairobi, Kenya, April 2009 Objectives: –define questions for MCP for inclusion in all future Demographic and Health Surveys –produce guidance on complementary methods for MCP measurement –develop the MCP research agenda Developed standard MCP indicator

9. 2. Recent meetings on MCP (cont.) Harvard University AIDS Prevention Research Program, UNAIDS RST ESA, and the World Bank Global HIV/AIDS Program: Addressing MCP in Southern Africa: Developing Guidance for Bold Actions Gaborone, Botswana, Jan 2009 Gaborone, Botswana, Jan 2009 Goal: to develop an agenda for action on MCP programming in the region Goal: to develop an agenda for action on MCP programming in the region

10. 3. Program guidance from Harvard APRP/UNAIDS/World Bank meeting To maximize prevention outomes around MCP the following two outcomes need to be prioritized: First Priority A reduction in multiple and concurrent partnerships through social and behavioural change and, where feasible, through addressing structural factors (such as lengthy separation of partners) that increase the likelihood of MCP Second Priority A reduction in the transmission of HIV within multiple and concurrent partnerships as well as within known discordant relationships including through consistent correct male or female condom use, male circumcision, HIV testing (though antibody tests during the acute infection period are generally negative) and treatment adherence

11. 3. Program guidance from Harvard APRP/UNAIDS/World Bank meeting Changes are needed in: sexual behaviours social values and norms that support and reinforce MCP and age-disparate sex implicit and explicit rules that “govern” societies the range of organizations involved in reducing MCP the scale of financial spending on MCP programming, so that it forms a far greater proportion of overall HIV and AIDS spending.

12. 3. Program guidance from Harvard APRP/UNAIDS/World Bank meeting Key principles and approaches: Develop a hierarchy of staged interventions, with MCP reduction the overarching focus and priority Focus on family, community and social normative change including building on existing responsibility to family and clan and, in some cases, fostering national “patriotic” responsibility and pride Particularly highlight the need to reduce and break up sexual networks

13. 3. Program guidance from Harvard APRP/UNAIDS/World Bank meeting Key principles and approaches (cont.) Develop messages that capture the grave seriousness of AIDS, including appropriately and sensitively handled “fear-appeal”-based approaches Develop messages tailored to address the particular vulnerability of people in long-term concurrent networks with relatively low overall numbers of sexual partners Include messages to address behavioral formation among the young, and encourage delay of sex for youth Messages about the interface between alcohol, MCP, casual sex, and unsafe sex

14. 3. Program guidance from Harvard APRP/UNAIDS/World Bank meeting Need for overarching slogan/message at regional level that can be adapted for use in local situations? (similar to Uganda’s “Zero Grazing”) Break the Network?

15. 4. Resources available for MCP programming and M&E A number of resources are available online– see handout for list

16. Thank you!