Skinning the goat and pulling the load:
HIV risk and violence among youth in
Tanzania
Suzanne Maman
Health Behavior and Health Education
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.
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).
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
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
Tanzania
Population: 33 million
Pop in Dar: ~ 3million
Per capita GNP: $246
Life expectancy: 45 years
HIV prevalence: 8.8%
Intervention Design
The intervention consists of two major components:
Peer support
• Young men
enrolled in
groups of 10-12
• Groups meet
monthly for 12months
• Facilitated by
trained peer
group leaders
Community
Theatre
• Trained theatre
group perform
interactive skits
• Performances in
venues frequented
by young men
• 3 different skits
performed 12
times
Research Design
Formative Phase
60 IDI
14 FGD
Evaluation Design
Intervention
475 men, 16-24 yrs
Control
475 men, 16-24 yrs
Interviewed baseline
Interviewed baseline
Participate in intervention
Interviewed 2 month
Post-intervention
IDIs with the female partners of 40 men
Interviewed 2-month
Post intervention
Formative and Baseline
Findings
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.
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
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.
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
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
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
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
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
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)
Conclusions
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
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
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
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
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.
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
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.