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Russia (2008): HIV/AIDS TRaC Study of Risk, Health-seeking Behaviors, and Their Determinants, Among Men Who Have Sex with Men in Eight Regions of the Russian Federation. Second Round.

March 18, 2009

Description of Intervention: PSI's LaSky program targeting MSM combines the distribution of informational and motivational materials to the target group with outreach activities, "edutainment" group sessions and inter-personal communications delivered by trained peer educators and opinion leaders. LaSky also supports an internet site with information, and a counseling telephone hotline.Methodology: The baseline survey in 2006 used time-location sampling; due to low response rates the follow-up in 2008 used respondent-driven sampling (RDS). Sample size was calculated for all the regions together. The baseline was a single-stage cluster sample, with locations where MSM congregate defined as clusters. The number of respondents to be selected was proportionate to cluster size. In every region the estimates of the number of MSM per cluster were calculated as a part of mapping exercise conducted prior to data collection. The follow-up in 2008 used the clusters defined in 2006 to select seeds (initial respondents). In large metropolitan centers (where the estimated number of total MSM in more than 20,000) four recruitment waves were completed. In smaller locations the estimated number of MSM is below 10,000, and three recruitment waves were completed. A total of 539 and 1113 interviews respectively were completed for the baseline and follow-up studies. Analyses consisted of logistic regression and anovas to examine trends over time, to ascertain which determinants are correlated with key behaviors, and to examine the association between program exposure and changes in health behaviors and determinants. Socio-demographic characteristics and geographic location were controlled for in the analyses.Main FindingsThe monitoring table highlights that:The share of respondents who report having relationships with a permanent partner has reached 82.0%, up from 68.3% two years ago (p value less than .001). Yet the number of respondents reporting having casual partners has also increased (p value less than .05), which suggests that MSM tend to maintain multiple sexual relationships at any given time.Condom use is far from being universal and varies by type of partner. In 2008, condom use at last sex with casual partners was 66.8%, and it was only 44.1% with permanent partners. The findings show a significant improvement in condom use among casual partners over time, but no change in condom use with permanent partners.The results of segmentation analysis indicate that the probability of MSM using condom during last contact with male partner increases with availability of free condoms. Almost 85% of those practicing safe sex report having received condoms for free, the respective figure for non-users is 77% (p value less than .01). Thus, the availability of free condoms encourages MSM to use condoms.Self-efficacy to discuss condom use. MSM who are confident in their ability to discuss condom use with different types of partners are more likely to use condoms at last sex with a male partner. The respective means are 2.86 for users and 2.58 for non-users (p value less than .001).Perception of condoms making sex less pleasant. Predictably, respondents who disagree with the statement "condoms make sex less pleasant" are more likely to use condoms than those who subscribe to this notion (45% vs. 30.2%, respectively, p value less than .001).The results of evaluation analysis reveal that PSI program exposure is associated with:An increase in condom use with casual partners as well as commercial partners (p value less than .05).A greater likelihood of being tested for STIs (p value less than .05).Increased confidence to negotiate condom use with different types of partners, being better informed about the requirement for HIV test being accompanied by pre-and post-test counseling, and knowing that it is not possible to tell by looking if a person has an STI (p value less than .05).A higher perception of being at risk for HIV (p value less than .05).There was no effect on the perception that condoms make sex less pleasant.

Expanding the Scale of Emergency Contraceptive Programme in Rajasthan

February 18, 2009

Reports outcomes of a program to expand access to and use of emergency contraceptives and other birth control methods in Rajasthan, India, through outreach, training, and sales via a revolving fund. Assesses the program's policy impact and sustainability.

Effectiveness of Male Condoms: Frequently Asked Questions

August 1, 2007

More than two decades of research and experience have provided new insights into the role of male condoms for contraception and HIV prevention. However, given that the number of people infected and living with HIV continues to grow, it is essential to reassess what we have learned about HIV prevention. This is especially true regarding condoms, the controversial mainstay of HIV prevention programs. Opinions on condoms are often based on ideology rather than evidence, though evidence has accumulated steadily. The following is a list of frequently asked questions and answers about condom efficacy.

Family Planning and HIV Prevention: Creating Synergies

August 1, 2007

Both family planning (FP) and its integration with HIV programs have been overshadowed by donor emphasis on other urgent health issues, namely HIV, malaria and tuberculosis. This is especially true in sub-Saharan Africa where the HIV epidemic is most acute, fertility rates are high and modern contraceptive use is low.1 This occurs despite the high unmet need for FP in the region and the proven impact of FP programming on a broad range of development goals, including health, poverty reduction and environmental sustainability. FP and HIV prevention interventions are synergistic in efforts to prevent unintended pregnancies and HIV, and their integration contributes to lessening the burden of other health and socio-economic challenges faced in the developing world.This brief discusses the lack of synergy between FP and HIV prevention interventions and the benefi ts increased synergy could bring. It discusses current limitations to contraceptive access and their effect on the potential for integration, and what PSI is doing to improve FP/HIV integration. PSI is committed to increasing and improving such integration in order to maximize health impact and cost-effi ciency.

Blended Models of Health Supply Starting To Show Promise in Developing Countries

June 1, 2006

Years of experience have shown that there is no single way to be successful in international development. What works depends on country conditions: the manner, number and capability of partners on the ground, and the state of the markets for health-related goods and services.Those markets generally mature over time. They may change as a result of political and social factors or new players entering the scene. When such conditions change, consumers generally become better educated and more discerning, and strategies for reaching those consumers must also evolve.This phenomenon is true of social marketing as well as the private sector. PSI is taking advantage of such changes in a number of countries to alter its market positioning in order to improve the cost-efficiency of its programs.

'Milking the Cow': Young Women's Constructions of Identity, Gender, Power and Risk in Transactional and Cross-Generational Sexual Relationships

March 1, 2005

This report presents the findings of a qualitative study carried out in Maputo, Mozambique, among women engaged in cross-generational transactional sex. Cross-generational sex is contributing significantly to the spread of HIV/AIDS in Mozambique and as such is a key area for behaviour change interventinos, although few organisations are currently addressing the issue. The study reveals thta young women engaged in cross-generational and transactional sex have a complex sexual network involving multiple partners, including both transactional and non-transactional relationships.The study was carried out between October and November 2004, using the PEER (participatory ethnographic evaluation and research) method. PEER is an innovative approach to programme research, evaluation and design, based upon training members of the target group (peer researchers) to carry out in-depth qualitative interviews among their peers. Twenty young women in the age group 16-25 years, living in and around central Maputo were recruited as peer researchers. Each peer researcher interviewed three peers and conducted three separate interviews with each peer, with a total of 180 interviews carried out.

Condom Programs in High HIV Prevalence Countries Should Include the General Population

August 1, 2004

This issue brief focuses on the principle that condoms should be promoted to the general population as well as high-risk groups, particularly in places with high HIV prevalence.

Cross-Generational Relationships in Kenya: Couples' Motivations, Risk Perception for STIs/HIV and Condom Use

February 11, 2003

Objectives: To understand women's and men's motivations for entering into cross-generational relationships and to examine how their risk perception for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) affects sexual decision-making and condom use.Methods: A total of eight focus groups were conducted with women aged 15 -- 19 and 28 indepth interviews were carried out with men aged 30 years and older in Nairobi, Mombasa, Kisumu, and Meru. Participants discussed motivations for entering into non-marital, crossgenerational relationships, perceived risks, relationship dynamics, and circumstances under which older men and younger women meet. Data analysis highlighted common and divergent themes on cross-generational relationships and the risks associated with them. Results: According to study participants, Kenyan men who pursue younger women do not fit a "sugar daddy" stereotype; rather they come from a variety of social and professional backgrounds. Young women actively seek partners who are willing to spend money on them whereas men look for partners who are well mannered, need money and have certain physical attributes. Women's primary incentive for engaging in cross-generational relationships is financial and material gain while men seek younger partners for sexual gratification. Pressure from peers to fit in and some family members to secure financial assistance from older partners can compel women to engage in cross-generational relationships. Although some peer groups support and encourage such relationships, other groups, especially wives, same-aged boyfriends and parents, disapprove of them. As a result, cross-generational couples are often preoccupied by the threat of discovery. Risk perception for STIs/HIV is low and couples rarely use condoms.Conclusions: Most cross-generational couples underestimate their risk for infection from STIs/ HIV. Young women believe that older men are low-risk partners because they are less likely to be promiscuous and more likely to remain faithful to younger partners and wives. Men believe that young partners are innocent and sexually inexperienced. Material gain, emotional factors, sexual gratification, and recognition from peers override the risk for STIs and HIV infection. Condom use is low and young women's ability to negotiate use is compromised by age disparities and economic dependence. Study findings suggest several programmatic strategies for targeting young women and older men. Behavior change communication campaigns should educate women and men about the increased risk of STIs/HIV associated with cross-generational relationships. Programs should also promote safer sexual practices, such as consistent condom use, within relationships. Campaigns could employ positive role models to encourage young women to seek safer alternatives to cross-generational relationships and decrease peer pressure among men to pursue such relationships. Long-term interventions include improving young women's access to educational and career opportunities, and working with communities to determine the best approach for changing social norms and the acceptability of cross-generational relationships.

Lubricant Social Marketing - Lessons Learned

November 1, 2002

With the most and longest experience social marketing lubricants, PSI is clearly the leader and within PSI is where the lessons learned primarily lie. The findings in this report come from the few PSI and Non-PSI lubricant social marketing projects implemented (or to be implemented) in Bolivia, Cote d'Ivoire, Romania, the Philippines, Nigeria, Laos, Bombay India, Myanmar, Papua New Guinea, and Central America and some projects distributing lubricants free of charge in Jamaica, India, South Africa, Hong Kong, and Chad. Most countries were very cooperative with sharing their lessons, however, with changes in project leadership valuable details of corporate memory have been lost. Even with PSI's pioneering in lubricants, in the midst of all the condom marketing, lubricants are a peripheral product. This report also examines the notion that "a condom is only as good as the lubricant."

Cross-Generational and Transactional Sexual Relations in Sub-Saharan Africa: Prevalence of Behavior and Implications for Negotiating Safer Sexual Practices

September 12, 2002

This literature review assesses the extent of sexual relations between adolescent girls and older male partners (cross-generational sex) in sub-Saharan Africa; the extent of transactional sex; and the behavioral dynamics of girls and men involved in these sexual relations. The underlying assumption, supported by emerging empirical study, is that sex with older men increases the girls' risk of becoming infected with HIV. Because there seems to be little programmatic attention to reducing HIV risk by focusing on these partnerships, the intention of this review is to inform the efforts of AIDSMark -- in particular, Population Services International and the International Center for Research on Women -- on how to reduce HIV risk by addressing sexual relationships between adolescent girls and older men. Over 45 quantitative and qualitative studies of crossgenerational and transactional sexual relations were reviewed.The review finds that engaging in sexual relations with older partners is the norm for adolescent girls. Sizeable proportions of girls' partners are more than six or 10 years older, although age differences with most current partners appear to be only a few years older. The data also reveal that select groups of girls, such as those who have become pregnant, have much older partners on average. There is a widespread transactional component to sexual relations for adolescent girls, and in some contexts, large proportions of girls have engaged in this type of relationship. It appears that, as adolescent girls mature, they engage in sexual relations with ever-older partners, and are more likely to have engaged in transactional sex. In addition, we find that men have large proportions of adolescent girls as non-marital sexual partners. However, due to the narrow definition of transactional sex in the survey questions, and the stigma of reporting exchange behaviors, these figures are likely to be underestimates.Several studies reveal significant relationships between unsafe sexual behaviors, HIV risk, and cross-generational sex. Three of these studies find that greater age differences between partners indicate a significant increase in adolescent girls' risk of HIV infection. Two additional studies find that unsafe behaviors -- including non-use of condoms and non-discussion of HIV with a partner -- are significantly linked to greater age differences between sexual partners. One study finds that transactions of greater value also have a significant effect on non-use of condoms.Although the motivations for adolescent girls to engage in sexual relationships with older men are varied and overlapping, gifts and other financial benefits was the major theme found. The motivations for financial rewards tend to be complex, ranging from economic survival to desire for status and possessions. Extreme household poverty as a motivator of sexual activity is described less often. Most studies point to girls' strategies to increase their life chances through education or work opportunities, or to pursue the enjoyment that goes along with adolescence and young adulthood. Gifts such as soap, perfume, dresses, meals out, and jewelry have become symbolic of a girl's worth and a man's interest, and girls who do not receive gifts in exchange for sexual relations are humiliated.Because of the limited negotiating power of adolescent girls with respect to sexuality and reproduction, sexual partnerships between adolescent girls and older men are fundamentally imbalanced, with men having more power. Girls appear to be able to negotiate relationship formation and continuance; for example, they can choose the types and number of partners they have, and can discontinue a relationship if gift-giving ceases. However, once in a sexual partnership, adolescent girls are less able to control sexual practices. Men appear to control the conditions of sexual intercourse, including condom and contraceptive use and the use of violence. Girls are not likely to insist on condom use for many reasons, including social norms and lack of selfperceived risk of HIV. On the whole, suggesting condom use jeopardizes their goals for the relationship, including the receipt of money and gifts.

Multi-Country Study on Trusted Partners among Youth: Eritrea, Tanzania, Zambia, and Zimbabwe

August 14, 2002

ObjectivesExplore youth's definitions of "trust"Establish criteria youth use to determine the trustworthiness of partnersIdentify types of individuals youth believe they can and cannot "trust"Examine trust's influence on sexual decision-making and STI/HIV risk perceptionIdentify how sexual partners violate trust and the effects on sexual decision-makingStudy designData were collected in October 2001 as part of a regional Behavior Change Communication (BCC) strategy in East and Southern Africa. Country programs chose to participate in research based on project priorities and levels of interest in participating in a regional BCC strategy. Four county programs agreed to collect and share data, Eritrea, Tanzania, Zambia, and Zimbabwe.A total of 33 focus groups were conducted. Research teams in each country used the same discussion guide and pretested the guide prior to data collection. Discussion groups lasted between an hour and an hour and a half, were audiotaped, and transcribed into English. Each research team conducted two discussion groups in the major urban area composed of the following strata: males 15-19 years, females 15-19 years, males 20-24 years, and females 20-24 years. The Zambia program conducted one additional focus group with males aged 15-19.FindingsExplore youth's definition of "trust" and criteria used to determine trustworthinessThe major components of trust did not vary greatly across countries. Youth in all countries placed a high value on sexual fidelity and its role in trusted partnerships. Youth believed that partners met through family or friends are more trustworthy than those met in bars or nightclubs. In addition, youth in all countries expressed that trusted partners must pass informal assessments, dress appropriately, demonstrate appropriate social conduct, talk sweetly to each other, come from the right neighborhood, meet one another's family, be punctual for appointments/dates, and remain emotionally committed to one another. Eritrean youth appeared to place greater importance on the roles that religion, virginity, and marriage (or intent to marry) play in establishing trust than youth from other countries.Differences in criteria for trust were more apparent by gender. In terms of testing partners' trustworthiness, females discussed passive ways of questioning partners, while males discussed elaborate methods for entrapping females in lies. Males were concerned with partners' sexual reputation and appearance. Females were primarily concerned with partners' emotional commitment, willingness to accept responsibility for pregnancies, and ability to display affection in public in order to demonstrate intimacy and trust.Identify types of individuals youth believe they can and cannot "trust"Across countries, youth place prospective partners into groups that can and cannot be trusted according to key attributes and behaviors. Similar to the findings above, most participants said that youth that come from good families, are well respected in the community, are religious, do not drink, avoid bars and nightclubs, and are faithful can be trusted. Youth believe that they cannot trust anyone outside of committed, monogamous relationships. Male participants added that virgins can be trusted.Examine trust's influence on sexual decision-making and STI/HIV risk perceptionYouth do not appear to take effective preventive measures with trusted partners. Trust can blind them to their risk for STIs/HIV and render them unwilling to explore partners' sexual histories. Sex usually occurs early in relationships and condom use remains low. When youth use condoms, they are more likely to incorporate them into casual than trusted relationships, or use them for pregnancy prevention rather than protection from STIs/HIV. Condoms are usually abandoned once relationships appear to be serious and partners fail to show signs or symptoms of STIs or HIV infection. There were few differences in risk perception and risk behavior across countries; however, male participants in Zambia reported that they discuss their sexual histories, while participants from other countries said that couples rarely discuss their sexual histories.Identify how sexual partners violate trust and the effects on sexual decision-makingInfidelity represents the most serious violation of trust and usually results in the end of relationships. A common theme across all countries was youth's refusal to learn from past experiences and apply them to future sexual decision-making. Even when trust is broken, youth fail to apply lessons learned to new relationships, repeating the same scenarios of trust, infidelity and exposure to STIs/HIV.Programmatic implicationsYouth must understand that partners' trustworthiness and character are independent of their risk for STIs/HIV. Although a checklist may help youth select a good partner, unprotected sex with this or any other person must be perceived as risky. Youth must also personalize their risk for STIs/HIV and avoid thinking that only people outside of their community are at risk for infection. It is likely that interpersonal communication campaigns or other community-level activities will help achieve an improved risk perception. Finally, in order to communicate new and appropriate levels of personal risk assessment, programs should strive to achieve broad social support, if not pressure for, consistent condom use, knowledge of one's own HIV status as well as that of all partners, and delay of sexual activity where possible.

Reasons for Non-use of Condoms in Eight Countries in Sub-Saharan Africa

March 22, 2002

Objective: To determine why sexually experienced males and females from multiple countries in sub-Saharan Africa do not use condoms.Methods: We used data from sample surveys conducted in eight countries in sub-Saharan Africa. Respondents were asked about their use of condoms and their reasons for not using a condom in last sex with a marital, a regular (non-marital) or a casual partner. Respondents' reasons for not using a condom are shown by type of partner and by gender. Results: Males and females most frequently reported trusting their partner as the main reason for not using a condom in last sex with a marital or a regular (non-marital) partner. This suggests that low personal risk perception is the most important reason for not using a condom with a marital or a regular partner. A dislike of condoms is the most frequently cited reason for not using a condom with a casual partner. Respondents rarely cited the price of condoms as a barrier to condom use. Lack of condom availability was also rarely cited as a reason for not using a condom, except to some degree by males in casual partnerships. The latter may be because of the unplanned nature of casual sex activity, rather than because condoms are not available. Conclusions: Behavior change campaigns encouraging sexually experienced people to accurately assess their personal risk of acquiring HIV should be complemented with marketing campaigns emphasizing the positive attributes of condoms.