A social norms approach to voluntary couple counseling & testing, ANC
and HIV/AIDS prevention in Tanzania
Case study by Justus Olielo – UPenn – UNICEF Programme 5-( 16 July 2010)
Executive Summary
Tanzania is one of 58 countries with a generalized HIV epidemic with the current
(2007/2008) prevalence rate estimated at 5.7% with regional variations . The major modes of
HIV transmission are heterosexual transmission (app.80%) and mother to child transmission
(app.20%). Nationally, less than 15% of couples are counseled and tested together for HIV.
While over 90% of women attend ante natal clinics (ANC) at least once during pregnancy but
only 42% of deliveries are assisted by qualified health workers
Available evidence show that promotion of couple testing for HIV has considerable benefits
in the overall ability of the individual and couple to respond more effectively to the threat of
HIV/AIDS. For instance, couples who receive voluntary counseling together are more likely
to;
 Be tested for HIV
 Disclose their HIV test results to their partners,
 Adopt safer sexual practices
 Adopt measures against transmission (facility delivery,
 Receive and comply with Anti-retrival therapy for self and infants (if +)
 Develop better child care practices (IYCF, psycho-social support
 Develop a more trusting relationship/family
Despite these glaring benefits, it hasn’t always been easy to get couples to attend counselling
sessions together. Deeply rooted social norms as well as personal beliefs, fears, and taboos
around sex and sexual relations makes it especially difficult for men to attend voluntary
counseling and testing (VCT) sessions. The empirical expectation is that men don’t
accompany their wives/women to the clinic (it’s women’s affair) and even without the risk
of HIV/AIDS, most men have anormative expectation of sanctions in cases of violation
including negative labelling/rumours, exclusion from peer and social networks
The possibility of testing HIV positive increases fear of stigma and discrimination as having
AIDS condition is seen as shameful, the result of personal irresponsibility or immoral sexual
behaviour and the individual is made to feel he is a let down on the family/community. Fear
of abandonment/rejection by partner family, community (especially for women) to the
negative perception of coupe testing
Since 2007 UNICEF has supported the government and partners to implement couple
counselling and testing through focused information, education and communication strategies
that de-mystify the prevention of mother to child transmission of HIV, open up an informed
dialogue about the issue of HIV/AIDS and pregnancy and in so doing, contribute to reduction
of stigma and improve health-seeking behaviour.
However, reviewing the programme from a social norms perspective show a number of
possible areas the interventions could be improved. For instance, more key messages and
attention has been placed on men/husbands of pregnant women and less on the social
networks that influence behaviour – social sanctions like stigma is not just from and by other
men but also from women (pregnant or not), children. Adopting a more holistic approach
with emphasis on the social networks to address empirical and normative expectations (with
sanctions) would ensure effective participation of women and men, leaders and youth.
More emphasis has been placed on the individual behaviour (picture a singular couple
attending ANC,) rather than collective behaviour. Promoting adoption of new social
conventions e.g. group attendance of couple counseling (not testing*) sessions thru’ snow
balling/organized diffusion approaches could help reduce perceived normative expectations
with sanctions and allow more men to attend.
More efforts could be placed in reducing dissonance between the dominant negative
associations of VCT/ANC (HIV, immorality) with the positive messaging of couple testing
(health, love,) and to do this, it is important to refocus the script with testing positioned less
as the goal and more as the means to a higher goal; better health for individual, family,
healthier stronger community, etc to which everyone should aspire. In so doing the
programme could benefit from highlighting the link between the desired behaviour (coup
testing/men accompanying their wives to ANC clinics) with the much cherished values of
masculinity and male roles as protectors/defenders of family and community, so that more
men begin to see going to the clinic with their wives as an extension of these roles, rather
than as negative deviation from established social norms.
Finally, it would be important ensure that the quality of service delivery, especially
counseling sessions, are much more aligned to the social norms - appreciative, non
judgmental, non directive - so that men attending do not feel alienated but respected and
welcome .