Deborah Mindry 1, Suzanne Maman 2, Admire Chirowodza 3, Tshifiwha Muravha 4, Heidi van Rooyen 3, Thomas Coates 1. 1.UCLA, Program in Global Health, Medicine, Infectious Diseases, Los Angeles, USA. 2.University of North Carolina, School of Global Public Health, Chapel Hill, USA. 3.Human Sciences Research Council, Child, Youth, Family and Social Development Programme, Durban, South Africa. 4.University of Witwatersrand, Perinatal HIV Research Unit, Joahnnesburg, South Africa Looking to the future: South African men and women negotiating HIV risk and relationship intimacy (Project Accept HPTN 043)

Introduction High rates of HIV infection, men and women (and families) are grappling with long term infection and illness and the fear of HIV transmission Great deal of insecurity in long term relationships since most not married and do not cohabit Individuals frequently face the challenges of balancing the risks of HIV whilst trying to maintain their relationships Research on couples/families living with long term illness highlighted the struggle to balance disease risks and illness while trying to maintain healthy relationships

Aim: We examine how and what approaches men and women in two South African settings used to engage their partners in discussions of HIV and to address HIV risk factors in their relationships

Methodology Project Accept (HPTN 043): Multi-site, multifaceted, community based trial - voluntary counseling and testing (VCT) model in 48 communities in 4 countries (South Africa, Zimbabwe, Tanzania, and Thailand Focus for this paper on South African sites: – 8 rural communities in Vulindlela, KwaZulu-Natal – 8 urban communities in Soweto, Johannesburg. In-depth qualitative interviews conducted at four points during the study (baseline, 6 months, 15 months). Interviews: HIV-related attitudes, norms, and behaviors of the individual as well as their perceptions of partners’, family members’, friends’ and community members’ attitudes and behavior Analysis focused on topical codes highlighted discussions the interviewee had with his/her partner regarding HIV and discussions regarding their partner’s attitudes to HIV testing and HIV more broadly

Participant demographics by site Vulindlela Baseline Vulindlela 6 months Vulindlela 15 months Soweto Baseline Soweto 6 months Soweto 15 months # of participants male/female 65/6244/4143/3745/5536/3733/29 Coupled/ Single 64/6145/3646/3342/5829/4522/40

Results 1.Gendered patterns in the negotiation of HIV Risk 2.Balancing disease risk and relationship risk 3.Approaches to managing risk in relationships

Gendered patterns in the negotiation of HIV risk Trust is a critically important issue that individuals were negotiating as they sought to maintain healthy relationships Discourses on trust revealed differing gendered expectations of partners: – Women had expectations and often acceptance of men having multiple partners – Both, had expectations that women initiate discussions of HIV and risk in their relationships Although men were often socially expected to initiate sexual relationships, women were generally expected to initiate discussions of HIV 1.

“It is not easy for a male person to think that they need to test because commonly males do not really care that much about that [testing]. The problem is with us females.” (11 January, 2006, 25 year old, coupled, female, Vulindlela). Women were often quite proactive in addressing the risks of infection in their relationships. A 25 y.o. woman in Soweto told an interviewer that: “I wanted to know as soon as, actually I wanted to even before we got together, because I had just broken up with someone I was sleeping with and I’m thinking I can’t be going into another relationship not knowing. Say I’m sick and then I get this (….), so I wanted to test to it. And then I postponed it and you know, each time you just don’t make time for it. You’ll think about it until eventually you’re sleeping with this person. Now that’s like one extra person you’re counting. Like there are so many people now it’s him as well. But if it happens that you are …, you have to tell so many people that it is like this you know.” (Soweto, 28 June 2006).

A man in Vulindlela told an interviewer: P: “No, I want her to be the one who will be the one who will tell me that you see, this is the way it is, besides she is the person that I trust, you see.… If things are bad in her, things will also be bad with me I: In what way? P: Maybe she gets sick, maybe suffering from AIDS, and I also suffer from that AIDS disease. Of course I will feel pity for her you see, she’s my partner.” (26 July 2006, 18 year old, coupled, male, Vulindlela). Women often reported an inability to persuade a reluctant partner to test. Men frequently relied on female partners to test as a means of determining their own HIV status. This phenomenon of men testing by proxy was not uncommon.

Balancing disease risk and relationship risk Cusick and Rhodes (2000) –research in the UK with HIV+ drug user found that the “rationality of safer sex” could be in conflict with individual’s and couple’s efforts to “signal the importance of the relationship”. Our study, couples attempted to weigh viral risk and relationship risk. – Married women, in long term relationship, or had a child, less likely to be able to insist on condom use with their child’s father – Men and women involved in casual relationships were more often able to negotiate condom use. 2

Balancing disease risk and relationship risk (cont.) Miller et al. (2009) – Kenyan’s sought to address sensitive issues with caution: – Often used intermediaries (church members, friends or family members) – Or a circuitous approach “until the bull’s eye at the center of their own relationship was reached” – The were balancing openness and privacy when considering HIV status disclosure. Our participants in South Africa: – Carefully negotiate HIV discussions in their relationships – Manage how, when and what information or concerns to share with their partners

A single woman in Vulindlela explained her relative risk of HIV in relation to her assessment of his character and their relationship. She told the interviewer: “But since you cannot predict a person, but he is a person who is careful, because when he does something you see whatever the circumstances are maybe, if you are in love, he just means it you see. Even if something is going to happen he explains that thing you see. And that he is not a person who fails quite often. You see if he does something, he does it and means it you see, such that you can end up guaranteeing him. And that when he says he loves me, he loves me you see. Maybe when he says he is so, it’s that you can see that he is like this. It’s that you see. So he is by nature like that. His nature is like that. So when it comes to HIV and AIDS I think I can give him sixty percent, you see, yes we can give him [that].” (24 August 2006, 24 year old, single, female, Vulindlela). She exhibits an acute awareness of uncertainty in her relationship. She considers her partner’s personality but expresses an awareness of the unpredictable nature of people. She acknowledges the risk of HIV/AIDS and even attempts to quantify the relative risk of infection that her partner represents.

Similarly, a single man in Soweto saw managing HIV risk in relationships as vital to sustaining a relationship. He told an interviewer: “I guarantee it's safe, it's better that we talk about it. In the relationship, then that's where you are able to see if a relationship, if you talk about these things, the relationship itself can be sustainable.” (17 August 2007, 24 year old, single, male, Soweto). Self-disclosure in a cultural context that generally preferences indirect communication strategies (Miller et al. 2009) can be risky but, as these extracts show, self- disclosure can also have potentially positive outcomes for sustaining a relationship.

Approaches to negotiating risk Approaches generally indirect – honing in on the issue in a more circuitous manner: – Initiating a discussion by expressing concerns regarding the HIV status of a family member or friend. – Media was another relatively safe vehicle for initiating discussions of HIV. – Occasionally, joking to “test” partner’s reactions. – Commonly, discussions of HIV emerged in the context of pregnancy or the desire to have children. 3

Initiating a discussion by expressing concerns regarding the HIV status of a family member or friend in the community “We spoke just as I have said this thing kills, it exists you understand. I told him about my aunts, this and this. So I’m scared I have children that I need to look after, I don’t want to die. And he also explained that you are speaking the truth. He also experienced such things with his family and 2 friends. So (….) it’s important for a person to know whether he’s dying or not and that he’s dying from this disease. Dying is for us all, but you have to know what is killing you” (11 September 2005, 25 year old, single, female, Soweto). Relatively safe approach for initiating a discussion of HIV Able to test out a partner’s reaction in a manner that would not implicate either partner directly Reference is made to HIV outside his/her relationship but used to hone in on specific concerns regarding HIV risk

Media a relatively safe vehicle for initiating discussions of HIV A man in Vulindlela discussed HIV with his partner, “Sometimes when we are watching TV, yes, when we are watching TV news, and then from there we discuss about the rate at which people are dying. For an example we compare the time frame and the number of deaths that have occurred, do you get what I’m saying?” (2 December 2005, 22 year old, coupled, male, Vulindlela). A woman in Soweto mentioned the TV program “Siyanqoba”, “You know once you start talking about Siyanqoba,... You know when it played on Sundays while I was at church… And he would say to me when I come back: “I was watching that program Siyanqoba, I heard them talking but was scared to even listen to what they were saying. But I know AIDS rules, but I'm still scared to listen to it.” You see such things.”(8 May 2007, 30 year old, coupled, female, Soweto). Television was a fairly neutral way to discuss HIV - a means through which individuals that were fearful of HIV/AIDS could more safely enter the realm of HIV.

Joking to “test” partner’s reactions A man in Vulindlela reported, “We have not discussed HIV, except that I sometimes say she must go and test her blood, you see, just like that, you see? Saying that in a joking manner, you see? That is what I usually tease her about and say, hey lady go and test blood here. …That is when I am just teasing her, you see, just teasing her, you see, to see if she does trust herself. …I do think that she gets really worried because she sometimes takes it as if I do not trust her, you see? Yes, she does feel sad indeed. …I end up being frightened; I then apologise and say no I was just joking.”(26 July 2006, 18 year old, coupled, male, Vulindlela). For women this joking strategy could be more risky. A 22 y.o. Vulindlela woman told us: “No, and [we] just talk … Because I once tested him and said, ei, I need to go and get my treatment. Do you know that we are both going to die? Ei, I saw that he changed the face, he changed his face. He said what are you saying? I said; please stop joking I am serious. Let’s go and get the treatment at Mafakathini (clinic). …Ei, you could see that he felt sad, you see he had that, that he wants to hit me, hhayi Icould see that, hhayibo, I am about to be beaten. I then said, hhayibo, I am joking Iwanted to see how you take things here in you. I said, hhayi, indeed I did see that on the day I am told that I have AIDS no you will hit me. He said, no actually I definitely will.” (28 May 2006, 22 year old, coupled, female, Vulindlela).

A more common approach to discussions of HIV emerged in the context of pregnancy or the desire to have children. A single female in Soweto raised concerns for her children’s future in her discussion of HIV with her partner: “He’s also afraid of the disease and he promised he never can go around or cheat on me or sleep with someone else, because I told him I can die of this disease. I have children, and I don’t wanna leave my children, my children behind. I wanna see them grow. I wanna see them finish school, go work and… I wanna life with my children. I don’t wanna the disease, so we talk openly not to go around, mess around cause it’s not nice even if you use protection, they are not made to go around so we talk openly about it.” (13 July 2006, 28 year old, single, female, Soweto). After attending an uncle’s funeral, a Soweto man told his regular girlfriend: “I told her that if we are not careful we will end up lying in that bed with no one crying for us, and I still have a lot of things I want to achieve, and also want to do some things for my mother. …You see, I still have to be on my own and go fetch my child so that she can grow up in my family. You see so that she can have her family culture.”(June 2007, 27 year old, coupled, male, Soweto).

Conclusions As men and women live with HIV/AIDS or the threat of HIV infection, they have to balance the risks of disease and illness with the challenges of maintaining a healthy relationship. They did so in a variety of ways: – Sometimes they openly revealed their HIV status – Cautiously approached HIV discussions - many reported their partner’s or their own fear of discussing it. – When necessary they withdrew from discussions of HIV. Their approaches entailed a careful management of the risks of addressing HIV in their relationships

Conclusions Our data suggests that concerns about children or desires to have children can be effectively used by men and women to raise concerns about HIV risk in their relationships. This appears to be a less threatening and more socially acceptable strategy as individuals attempt to balance the risks of infection while managing the challenges of maintaining a relationship. HIV prevention programs in South Africa would do well to address the mutual interests and investments of men and women in children by drawing partners into systems of care. Men and women can more effectively negotiate HIV risk in their relationships as they look to the futures of their children and invest in the future of their relationships.

Acknowledgements Funders and Project Accept colleagues Deborah Mindry and co-authors Citations: – Cusick, Linda, and Tim Rhodes Sustaining sexual safety in relationships: HIV positive people and their sexual partners. Culture, Health and Sexuality 2, 4: – Miller, A. N., Golding, L., wa Ngula, K., et al Couples’ communication on sexual and relational issues among the Akamba in Kenya. African Journal of AIDS Research 8, 1: