Understandings and Interpretations of Communication Campaign Messages about Concurrent Partnerships, Acute HIV Infection and Sexual Networks in Botswana and Tanzania

This 35-page report shares findings of a study conducted by Research to Prevention(R2P), based at the Johns Hopkins University, exploring local understandings of communication campaign messages on acute HIV infection, Concurrent Partners (CP), and sexual networks in Tanzania and Botswana. The research sought to understand how these interpretations fit within the larger cultural contexts. According to the report, CP can heighten the risk of infection by increasing the number of HIV transmission opportunities in general, and particularly during acute HIV infection.

The report explains that communication campaigns are a cornerstone of global HIV prevention efforts. Typically, these campaigns disseminate health messages designed to increase public knowledge about HIV and challenge social norms that legitimise HIV risk behaviours such as CP. They utilise a variety of strategies and channels to disseminate these messages, generally combining mass media, community-level activities, and individual-level activities to reinforce messages under a unified platform. Mass media campaigns have shown mixed effectiveness in changing HIV-related knowledge, attitudes, and behaviours. However, evaluations of communication campaigns generally measure indicators such as campaign coverage, HIV-related knowledge, and reported sexual risk behaviours. Little is known about how people understand and interpret the terms and constructs promoted through such campaigns or about the way the cultural context affects these interpretations.

In light of these gaps, the specific aims of this study were:
1. To explore how individuals in Botswana and Tanzania interpret communication campaign messages about CP, acute HIV infection, and sexual networks.

2. To understand how local understandings and interpretations of CP, acute HIV infection, and sexual networks fit within the larger social context surrounding sexual behavior and HIV prevention decision-making in Botswana and Tanzania.

The report outline the following results.

• Understandings of acute HIV infection, concurrent partnerships and sexual networks. In Tanzania, most participants expressed a narrow understanding of acute HIV infection, correctly noting that this was an early phase of infection but not describing the associated increase in Viremia. This interpretation was likely influenced by the translation of the phrase into Swahili. In Botswana, the majority of participants stated that they had neither heard of nor seen campaign messages or materials on acute HIV infection. A few participants in Botswana, however, were able to correctly identify the acute phase of HIV infection and its association with increased viral load and HIV transmission. Participants generally understood the relationship between CP and sexual networks, although some had difficulty distinguishing between the two concepts, particularly in Botswana. In both countries there was a broad understanding that being in a concurrent sexual partnership or knowingly or unknowingly being part of a sexual network increases risk of HIV infection. Many participants described the increased risk of acquiring HIV or other sexually transmitted infections (STIs) resulting from CP and sexual networks as not being able to truly trust one’s partner.
• Local terminology for CP and related behaviours: In both countries, additional local terms were used to describe CP and related behaviours. In Tanzania, participants referred to men with multiple and concurrent partners as Fataki, following a recent communication campaign, and used several local metaphors suggesting that CP are necessary for stability and security. In Botswana, participants commonly referred to extramarital relationships as "small houses," a "side dish" or a "snack".
• Experience with communication campaigns: To reach a broad audience, participants in both settings recommended using a mix of media channels to reach those who may not have access to television or radio, including billboards, flyers, home visits, and mobile technology. Small group discussions were particularly recommended. Certain campaign messages resonated with participants, particularly through dramas and discussions.
• Abstract campaign messages: In both countries, participants stated they had difficulty understanding some campaign messages. In Tanzania, some participants complained that abstract messages were “riddles” or “puzzles” that were difficult to decipher. In Botswana, one campaign tried to challenge cultural proverbs that support multiple partnerships. Participants said that such messages could be confusing, as it was unclear whether the message was intended to support or challenge the proverb.
• Credibility of the messenger: Public figures were often used in the Botswana campaign. While some believed that target audiences, especially youth, would value what famous people had to say, others believed that messages may be better accepted if delivered by a more appropriate role model. There were some concerns that the public reputation of some of the figures used did not support the intended message. Though Tanzanian campaigns did not use public figures, participants did comment that any messenger charged with promoting campaign ideas should be living out the principles he or she is teaching.
• Effect of campaigns on individuals: In both countries, some participants stated that the campaigns had made them more aware of risk of HIV infection and they had taken steps to protect themselves. However, others reported that the campaigns had had little effect on them. Challenges to achieving behaviour change included the public’s fatigue with HIV prevention campaigns, the difficulty in promoting sustained behaviour change, and cultural norms that uphold CP and discourage discussion about topics related to sex

The study concluded that individual decisions about sexual partnerships and concurrency are complex and situated within widespread social norms and economic structures. HIV prevention communication campaigns around the concepts of CP, sexual networks, and acute HIV infection should be attentive to how they are understood by viewers and how they employ cultural scripts. They should avoid inadvertently promoting cultural scripts that support CP and consider how they might facilitate protective behaviour through promoting new or positive cultural scripts. Programmes should continue to use best practices in health communications, such as pretesting messages, employing a mix of media, and including small-group discussions where feasible, to reach as wide an audience as possible with messages that resonate. Further, campaigns should encourage discussion about sexual behaviour within communities or couples and consider not only how they can influence current social norms, but also how they can encourage critical thinking and conscious decision-making to help individuals make positive life choices.