Addressing Multiple and Concurrent Partnerships in Southern Africa: Developing Guidance for Bold Action

This 19-page report emerges from a 2-day meeting on "Addressing MCP in Southern Africa: Developing Guidance for Bold Actions." Co-hosted by the AIDS Prevention Research Project (APRP) at Harvard University (in Massachusetts, the United States), the World Bank, and the Joint United Nations Programme on HIV/AIDS (UNAIDS), the meeting brought together approximately 40 representatives from various organisations working in the southern Africa region with the aim of establishing a common vision and agenda to guide interventions and strategies addressing multiple and concurrent partnerships (MCP).

"Diverse issues arose regarding MCP reduction in hyper-endemic countries, but with common agreement that it is an essential and priority strategy that needs to link effectively with wider HIV prevention approaches, and national level MCP reduction strategies should be rapidly developed and implemented."

Key principles to guide MCP programming are outlined here, including that "it must be based on sound evidence regarding the epidemic and the existing responses and unmet needs. It needs to be a coherent strategy and to operate at different levels, but with the specific solutions and messages to be community-driven. Both social transformative and individual behaviour change approaches are required, and there must be consistency and complementarity between them and in the approaches taken by the various stakeholders."

The document continues with the advice that, "To be effective, reducing MCP, and particularly concurrency in long-term relationships, needs to be the overarching message for behaviour change in the sexually active population, with accurate risk perception the foremost objective. Beyond this, programming needs to address different sectors of the population in appropriate ways to promote and reinforce this social and behavioural change. It also needs to take into account that in high risk settings such as sex work or casual sex, for example, condom programming is key; among young people, MCP messaging, while critical, must also relate effectively to messaging about age-disparate sex and to condom use and delayed sexual debut. The way that MCP messaging is prioritised and the specific messages developed must resonate with and be drawn from the population groups they aim to influence."

Other considerations discussed by meeting participants included: how best to involve faith organisations, and whether moralistic messaging from local faith groups could be useful provided it does not detract from condom messaging; the role of parents in reinforcing safe behaviours in their children, and how to deal effectively with negative role models, such as MTV; developing approaches to help couples build relationship skills, respect, communication about relationships and their sex life, and positive conflict resolution skills; and the various clinical settings where MCP messages can be usefully brought in - for example, voluntary counselling and testing (VCT), sexually transmitted infection (STI) clinics, and antenatal and male circumcision services.

Discussion of mass media approaches also led to consideration of diverse approaches and messages, including: whether appeal can be made to national pride in reducing HIV as well as to personal gain; the potentially constructive use of moralising if it comes from credible local role models and leaders; the potentially creative use of fear generation in balance with messages that enable action and positive benefits of reduced MCP; and using mass media to develop more complex and nuanced messaging over time, integrating MCP with other HIV prevention messages. Meeting participants also discussed the negative side of many soap operas and other popular television and radio programmes that glamorise MCP and whether creative ways can be found to counteract them.

As highlighted in this meeting report, longer-term approaches also need consideration, since structural and contextual changes - e.g., policies related to gender issues and income inequality - may reduce risk environments for MCP. Participants suggested that some contextual changes could be achieved quickly at local level. In some cases, simple incentives might have impact: one approach being assessed in Tanzania is making cash awards to those testing HIV-negative at STI clinics.

The next major topic of discussion was measurement - not just of specific programmes, but also to make comparisons between settings within countries and between countries. Participants noted that this requires some broad regional, national, and local agreement on key indicators and methodologies. "In addition, local communities need access to monitoring and evaluation of programmes that affect them, and their active involvement in participatory approaches to monitoring and evaluation and access to the findings in an accessible form should be assured."

Participants asserted that measures to show success would need to reflect positive changes in:

• inputs: increased spending on prevention and, within this, increased resource allocation to MCP reduction.
• outputs (process measures): numbers of people reached by particular activities; tools developed; frequency and quality of relevant media articles; number and nature of policies developed to support MCP reduction.
• impact (outcome measures): indicators such as percent of people reporting 2+ partners during the last month (or concurrently at any time during the past 12 months); percentage of people with a partner who has other partners; percentage of couples going for VCT, or percentage of counsellors who have talked about MCP; attitude measures (e.g., acceptability of having a relationship with a married partner, having more than one partner at a time, sexual relationships outside of marriage/long-term partnership); and percent of people who have discussed the quality and satisfaction in their sex life with their partner.

In concluding, meeting participants stressed that 3 primary elements must be in place:

1. National policy and programming efforts giving high priority to MCP strategies that incorporate social transformation approaches to complement approaches for individual behaviour change.
2. Appropriate monitoring and evaluation methods and indicators agreed and applied with consistency and rigour.
3. Continued sharing between country programmes and projects in the region to build on experience of what works, to learn by doing, and to avoid contradictory messaging and approaches.

"To achieve these will require strong advocacy at all levels of political, traditional, faith and other leadership, and technical support to regional, national and local partners to develop the necessary information and skills base to implement effective programmes. Approaches will need to be multisectoral and multi-faceted, with close interactive involvement with communities, the media and other collaborative partners to develop a strong, supportive community of practice within and between countries. MCP reduction, while a priority in its own right, also needs to link effectively with other prevention strategies and messaging."

Next steps identified in the document include:

• Development and dissemination of a regional guidance note on MCP (a preliminary/draft note is attached as an annex.)
• Forming a hub of experts in MCP programming to provide technical assistance and capacity building in rolling out MCP programmes, and to elaborate an advocacy agenda.
• Establishing a network of communication practitioners working on HIV prevention and social change communication. The network will organise around a virtual platform to share information, promote synergies, identify and seek support for obstacles in the implementation of programmes, etc.
• Mobilising political awareness by engaging political and opinion leaders around MCP, e.g. at Ministers of Health meetings.
• Capitalising on regional meetings to share country experience, the guidance document, and developments in indicator and target-setting.