PROMOTING COUPLE TESTING FOR PREVENTION OF MOTHER TO CHILD
TRANSMISSION (PMTCT) OF HIV INFECTIONS IN TANZANIA
(Case study by Justus Olielo for Advances in social norms course- University of Penn. 5-16 July 2010)
Background
Tanzania is one of 58 countries with a generalized HIV epidemic. Although the HIV prevalence
is going down with a decline observed from 7 percent in 2003/4 to 5.7% in 2007/8, many new
infections are still occurring. The major modes of HIV transmission are heterosexual transmission
and mother to child transmission. In the absence of any intervention, it is estimated that mother to
child HIV transmission contributes over 50,000 new infections among children per year,
representing about 20% of all new HIV infections in the country.
The government of Tanzania has put in place a national policy and legislative framework to
prioritize the needs of children living with HIV/AIDS and mitigate its impact.
Interventions have focused on improving access to and quality of PMTCT services including
voluntary counseling and testing of parents for HIV, improving access to treatment and ART
compliance by pregnant women, children, their partners and household members while providing
quality continuum of care and treatment support within the family and community
This case study highlights a crucial component of the programme intervention, namely promotion
of couple testing as a way of reducing risk and incidences of MTCT.
Rationale
There is evidence that seeking HIV voluntary counseling and testing (VCT) services is highly
effective in reducing sexual risk behaviour and reducing the likelihood of MTCT. In one
cited1 VCT trial conducted between 1995 and 1998 in Kenya, Tanzania, and Trinidad,
couples who were counseled together were more likely to disclose their HIV test results to
their sexual partners (91 percent did so), which reduced sexual risk behaviour. Those who
received couples voluntary counseling and testing were more likely to use preventive
measures against transmission (90 vs. 60%) and to receive nevirapine for themselves (55 vs.
24%) and their infants (55 vs. 22%) as compared to women who tested alone.
In a similar study in 3 VCT clinics in Dar es Salaam, women reported that the greatest
barriers to HIV testing and test disclosure were decision-making and communication between
partners, partners' attitudes towards HIV testing, and the fear of partners' reactions. For some
women who chose to disclose their HIV-positive status, negative reactions, particularly
abandonment by partner, and increased stigma from the family and community were fears
that were most likely to become a reality
From 2007 UNICEF has supported the government and partners to implement couple testing
as a behaviour change communication (BCC) intervention in 7 districts aimed at improving
access to voluntary counseling and testing (VCT) services through focused information,
education and communication strategies that de-mystify the prevention of mother to child
1
http://www.fhi.org/en/rh/pubs/network/v21_4/nwvol21-4partdiscus.htm
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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.
In 2009, following a review with local and government officials and partners, it became clear
that while radio and printed materials were effective in reaching a wider audience, this reach
did not effectively translate into understanding of benefits of the couple testing, did not
address the specific concerns of both men and women with regard to couple testing, and did
not clearly link the information to the provision of services, including where, how and when
to access the services and ultimately did not result in more men seeking couple testing or
attending ANC with their partners
It was then decided to place greater emphasis on interpersonal communication channels,
using mostly face to face interactions. This has since been extensively used in two districts of
Makete and Temeke, the former being a predominantly rural district while the latter is an
urban district within the capital city of Dar es Salaam.
Interpersonal communication activities have included the use of community dialogue and
focus group discussions with men, community leaders (both women and men) at village and
ward level, facilitated drama sessions using local drama groups, home visits by community
owned resource persons (CoRPs) – volunteer members selected by the community to be
trained to facilitate community awareness, participation in specific issues such malaria,
HIV/AIDS, sanitation, radio magazine programmes using local (FM) radio stations.
Interventions have emphasized getting more men to accompany their wives/partners for VCT
during ANC attendance, provide accurate and relevant information to HIV positive couples
about PMTCT including infant feeding practices, provide a supportive home and community
environment for HIV positive women/couples (by reducing stigma), support HIV positive
couple access ARV therapy, and promote health facility based delivery of the new born to
prevent the risk of infection during delivery
In all cases, the messages have moved from general awareness around VCT for couples
(know your status) to explaining to men how supporting and undergoing couple testing is
consistent with their traditional and cherished male roles of protecting and caring for the
family/new born, leading by example in the community, having a loving and trusting and
loving family relationship and how they individually stand to gain by knowing their HIV
status (access to ART if positive, adopting safer, healthier lifestyles, living longer etc)
The table below shows the trends of couple testing in the two districts compared with the
national trends, since 2007
Involvement Data for Temeke and Makete compared with National data
%
of
male %
of
male %
of
male
partners tested partners tested partners tested
for HIV in 2007 for HIV in 2008 for HIV in 2009
Makete
10%
26%
50%
Temeke
34%
National
No data
8%
15%
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The Social Norms Context of couple testing and Ante Natal Clinic (ANC) attendance
Understanding the challenges of couple testing and male participation in ante natal clinic
attendance requires an understanding of the social script (and sub scripts) that govern and
regulate sex and reproductive health relations in Tanzania generally and in specific
community contexts. In most societies in Tanzania, sex is rarely discussed, especially
between men and women together, or between couples, and between adults and children.
However, it is not uncommon for men and women to discuss sex among their respective
groups, even though care is always taken to exclude those who are deemed not to belong to
the social group, irrespective of gender. Exclusion can take the form of use of language and
imagery that is only apparent to the exclusive referent group or conducting the discussions in
an exclusive location. However, HIV/AIDS epidemic has put extraordinary pressure for
communities to break from the norm “of silence” around sex and, not just because over 80%
of infections in Tanzania are through heterosexual relationships but also because it has far
reaching ramifications for the overall capacity of individuals, communities and governments
to respond much more effectively.
Studies have consistently shown that “people associate HIV infection with the violation of
sexual taboos as well as certain death, and people with the infection may suffer from
discrimination in Tanzania. AIDS is seen as a shameful and life-threatening disease that is the
result of personal irresponsibility or immoral behaviour”2. Similarly a study on stigma and
discrimination conducted in Ethiopia, Tanzania, and Zambia3 shows that stigma around HIV
and AIDS “persists so tenaciously because it is deeply enmeshed with social and personal
views, beliefs, fears, and taboos around sex and death”.
These associations provide powerful pointers to the slow take-up of couple testing and male
participation in ante natal clinic attendance in many districts in Tanzania, as it challenges
deeply rooted social norms. All factors remaining equal, the motivation and possibility of
couples taking up HIV testing or visiting the ANC clinic together is greatly diminished not
only because of o the possibility of testing HIV positive (and risk of exposure to stigma and
discrimination) but also because it provides obvious tensions/conflic between the needs of the
individual (knowing his HIV status, loving his family) and how society expects him to
display his masculinity.
Typically, men in Tanzania would not even dream of accompanying their wives to ante natal
clinic as, even in the best of circumstances (without the stigma of HIV testing), management
of pregnancy and related activities including ANC clinic attendance is traditionally seen as
“woman thing”. As if to justify their exclusion of men, the ANC clinics are themselves often
a rowdy mix of pregnant and newly delivered women attended to by (often harassed and
mostly female,) health nurse who double as a health educator. This is a definite turn-off for
most men. Thus the empirical expectation that “men don’t go with their wives to the antenatal
clinics” is engrained in the social DNA of most men in Tanzania and there is most certainly a
normative expectation of sanctions in cases of violation, often in the form of negative
labeling/rumours, exclusion from peer and social networks, reduced social standing or
2
Avert. 2008. AVERTing HIV and AIDS. http://www.avert.org
Nyblade et all, Disentangling HIV and AIDS Stigma (2003), International Centre for Research on Women
(ICRW)
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esteem, etc. The default male reaction to messages and services promoting couple attendance
(and testing) is almost certain to be negative where there is pervasive perception of sanctions
should there be a breach of established social norms. This presents considerable social
dilemma to men who would otherwise want to accompany their wives to the clinics and
undertake couple testing.
Applying the coordination game theory to the likelihood of men adopting the desired
behaviour indicates the different levels of challenges they are likely to face before a
conducive environment for a new social norm is established and sustained.
Scenario 1: without personal motivation/information
and with stigma
Other
Self
Going to the
clinic
Not going to
the clinic
Going to the
clinic
Not going to
the clinic
1
2
1
-7
-7
0
2
0
This presents a social dilemma situation. Without motivation and information, the cost to the
individual going to the clinic alone is much greater than if both the individual and others
went, even with stigma. Although everyone would be better off if all the men accompanied
their wives to the clinic, the fear of stigma and discrimination makes each individual better
off not going. In this case, emphasis should be on providing information/motivation to the
individual and removing the stigma. This requires adopting of a holistic approach in analysis
and engagement of the social networks /community structures that facilitate credible and
effective information flows (Ryan Muldoon) as a basis for alternatives to the dominant
empirical and normative expectations. This may not sufficiently address the deep rooted
stigma, even though the community (of men) have the information and could be motivated
(as individuals) to accompany their wives to ANC. This leads us to the second possible
scenario;
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Scenario 2: with personal motivation/ information
and with stigma
Other
Self
Going to the
clinic
Not going to
the clinic
Going to the
clinic
Not going to
the clinic
5
2
5
-3
-3
0
2
0
In this instance, there are two equilibria: both go to the clinic, or neither goes. The problem is
that they may be stuck in the wrong equilibrium (neither goes).
With motivation and information, the individual may feel inclined to apply reversed
conditional preference by breaking the norm without expecting others to follow his example
as the benefit to him (of getting tested, protecting his child/family) could outweigh his
compliance with the norm (not going to the clinic). Although this scenario is less likely to be
sustained if the individual face and feel pressure of sanctions from his peers and community,
it does offer opportunity for organized diffusion whereby the benefit to him for breaking with
the norm is held up as an example for others to follow with the intention of reaching a critical
mass of adopters. It would be crucial at this stage to provide both positive external and
internal incentives to support the individuals sustain this behaviour since, as Erte Xiao noted
in her presentation, “norms may freeze the behaviour in place. Individual agents have little
control over social norms even when they wish these to be very different from what they
are”. In this case, external incentives would include improvement in ANC clinics to make
them more male-friendly (in a manner consistent with prevailing social norms) including
improving the skills of health service providers to better observe expected social etiquette
(e.g. calling out loudly surnames of adult men) . An attractive but unsustainable alternative
would be to promote home based counseling and testing services but this is unlikely to break
the social barriers as it may be perceived to be targeting individuals rather than the societyAt
the internal incentive level, adopters should be encouraged to take pride in their action and to
perceive themselves as pioneers, caring and loving husbands/fathers who care not just about
themselves and their families, but also about the wellbeing of the community – a community
who knows their HIV status and protects their families, who is a healthy and strong
community. This essentially means rewriting the social script by recasting and recategorizing
the image of men who accompany their wives to the ANC from being seen as weakling antisocials to those of strong, caring, supportive and pioneering family men and leaders in the
community.
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With more men accepting and adopting the practice of couple testing and accompanying their
wives to the clinic, there would be need for public demonstration of their commitment and
pride in their new behaviour, for example, encouraging collective clinic attendance for
counseling sessions (it may be counterproductive to promote collective testing as it has
implications on confidentiality and disclosure of test results), helping to reduce stigma.
Once stigma is eliminated, or otherwise substantially reduced to be no longer a point of
consideration, what remains is a conducive environment in which the behaviour (of couple
testing and ANC clinic attendance) can routinely be observed without fear or risk of
sanctions. There is now only one equilibrium, going to the clinic because the obstructing
conditions (lack of information/motivation and fear of stigma) have been effectively
removed. This is when the programme needs active reinforcement for example public
declaration that couple testing is a public good and that men accompanying their wives to the
clinic is a desirable behaviour supported not just by leaders, government but also by peers,
women in the community, and individual wives/partners.
with personal motivation/information
and without stigma
Other
Self
Going to the
clinic
Not going to
the clinic
Going to the
clinic
Not going to
the clinic
5
2
5
2
2
0
2
0
Conclusions
Understanding and applying social norms in t couple testing and male participation in ANC
attendance offers profound insight into the complexity (and interconnectivity) of behaviours
that collectively contribute to how well communities adopt or reject the intended behaviours.
It is noteworthy that Makete district which has shown the most promise, is a rural district
where social networks are much stronger and individuals are most likely to know and be
related to each other, thus a decision is much more likely to be communal rather than
individualistic, thus it is likely that more men collectively decide to go with their wives for
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VCT. It is also possible that the information (about their couple testing) is more likely to be
communicated back to the village much faster and in a more transparent manner, similarly
the benefits of couple testing is much more easily observable within a “homogenous”
community than in a cosmopolitan setting like in Temeke.For more communities to adopt
couple testing it will require more concerted efforts to identify and address the underlying
social norms that could work for or against the uptake of services including providing the
requisite incentives and or recategorization of behaviours that would make adoption more
attractive and acceptable.
Among the key recommendations for making this programme more responsive to social
norms would be adoption of a more holistic approach with emphasis on the social networks
to address empirical and normative expectations. Changing the language of social (less about
HIV/AIDS more about family and community values) and reducing the dissonance between
the dominant negative associations of VCT/ANC (HIV, immorality) with the positive
messaging of couple testing (health, love,) would help in changing perceptions.
Lastly, using snowballing and or organized diffusion models, promoting new social
conventions (e.g. group attendance of couple counseling sessions) and adopting a more
appreciative, non judgmental, non directive approach to men who attend ANC sessions, could
just prove to the tipping point in making couple counseling and testing a social norm in
Tanzania.
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