HIV Prevention Among Adult Women: Opportunities for Social and Behavior Change Communication

"Study findings show that HIV and AIDS communication has reached widely into study communities...."

This study is intended to inform strategic responses for addressing HIV prevention through social and behaviour change communication (SBCC) among adult women in the southern Africa region. Research questions addressed three main areas of enquiry:

1. How do community members understand HIV vulnerability and risky sexual behaviours that sustain high HIV prevalence among adult women?
2. Are there emerging concepts among community members that provide insight into reducing vulnerability and risk to HIV among adult women?
3. What are the opportunities for SBCC programmes to address HIV prevention among adult women?

This study in South Africa is part of a larger C-Change study that includes two other focal countries: Ethiopia and Namibia. C-Change conducted focus group discussions with men and women ages 20-50 and in-depth interviews with community and traditional leaders, healthcare providers, and staff members of non-governmental organisations (NGOs) across four provinces, in five communities representative of rural, urban, and informal urban settlements. The analysis drew on the socio-ecological model adapted by C-Change, which highlights four overlapping contextual domains - individual, socio-cultural, economic, and environmental - as well as crosscutting issues relevant to SBCC in the context of health. Two interpretive models were developed to further guide the data analysis. The first addresses the factors that underpin sustained high HIV prevalence among adult women. The second draws on change elements expressed in C-Change's socio-ecological model: information, motivation, ability to act, and norms.

Study participants described why and how adult women were vulnerable to HIV and why high levels of HIV prevalence prevailed. Across communities, the study found that common factors underpinning HIV vulnerability were largely related to economic inequality and exposure to alcohol consumption, with gender being a related issue. At the broadest level, adult women faced a continuum of vulnerability to HIV, even if their direct risk behaviours changed over time. Where risk behaviours were reduced, vulnerability to HIV flowed from ongoing relationships with risky male partners. Vulnerability and risk were also perpetrated by socio-cultural factors, such as acceptance of turnover of sexual partners as a characteristic of intimate relationships and a lack of accountability between sexual partners in relation to HIV prevention. A combination of factors has reduced the likelihood of long-term sexual relationships and marriage for adult women, including an emphasis on ongoing education and employment for women and delaying marriage to reduce dependence on men. While recent transformations have decreased gendered disempowerment of women, they have not sufficiently diminished adult women's vulnerability to HIV.

Both male and female participants mentioned personal strategies to address HIV prevention. These included acknowledging and internalising HIV risk and being motivated, through self-respect, self-care, and self-efficacy, to have sexually responsible relationships.

In addition to showing that HIV and AIDS communication has reached widely into study communities, the narratives illustrate that participants have applied the knowledge acquired about HIV to their contexts, to the extent that they understand HIV vulnerabilities and risks among adult women. The narratives also show that participants are critical of the ways that HIV prevention communication is delivered. Some see door-to-door campaigns as overly intrusive. They also expressed concern that some AIDS educators and authority figures were seen to be engaged in risky sexual practices themselves. Participants also highlighted contradictions in the overly sexualised content of some HIV-prevention messaging. Perceptions of gaps and opportunities for addressing HIV vulnerability and risk among adult women were voiced in similar ways across communities.

Participants emphasised the need to transform HIV knowledge into action through greater levels of community engagement, including involvement in problem-solving. They were confident that by working together, they could formulate locally appropriate strategies and solutions, noting that emergent groups, mainly among women, were already doing this. Male participants voiced concerns about the impact of HIV on the women in their lives and the community in general, highlighting that they had not been adequately drawn into processes for addressing the disease. Participants also noted that traditional and community leaders have not been adequately engaged in the prevention response, and their role in social mobilisation is insufficiently emphasised.

Implications for policy and programmes are described. Study participants viewed vertically driven, national-level, HIV prevention programme as "problematic for behavior change, since community members are not engaged in critical reflection and problem-solving for HIV prevention....[P]articipants called for the development and expansion of horizontal systems of response that are led on the ground and incorporate contextually relevant solutions. Key elements for community participation and social mobilization in HIV-prevention programming through SBCC could potentially include the following:

• collaborative ownership and leadership by implementing agencies, community leaders, and community members
• integration of local knowledge and problem-solving strategies
• contextually appropriate communication focused on translating knowledge into action, supported by promoting new and transformative social norms in relation to HIV vulnerability and risk
• integration and synergy with existing programs and services
• ongoing adaptation, as community-level responses evolve into new formats, and taking into account the evolving epidemic

In sum, these key elements highlight the importance of the 'social' in SBCC. Communication approaches such as Stepping Stones and Community Conversations in eastern and southern Africa have moved away from individually oriented communication in favor of group discussion, reflection, and action to achieve normative and individual changes in behavior....Such approaches offer the potential to bring about a broader social mobilization to address HIV risk and vulnerability and reframe social norms to support HIV prevention."