Docstoc

Definitions and Measures of Multiple and Concurrent Partnerships

Document Sample
Definitions and Measures of Multiple and Concurrent Partnerships Powered By Docstoc
					 The World Bank Global HIV/AIDS Program (GHAP)




Definitions and Measures of Multiple
and Concurrent Partnerships




                                                                  Masauso Nzima
                                                                  UNAIDS RST-ESA
                                                                   Johannesburg
                                                                       May 2009


                                    UNAIDS RST-ESA Johannesburg
      The World Bank Global HIV/AIDS Program (GHAP)



Presentation Outline
•   Changes that we want to see with MCP efforts
•   Indicators to measure the changes
•   Measurement methods
•   Where to next? Future developments




                                        UNAIDS RST-ESA Johannesburg
   The World Bank Global HIV/AIDS Program (GHAP)




Some Background

• Multiple and concurrent sexual partnerships
  facilitate rapid HIV spread (particularly in
  Southern Africa);
• Discussions and research on specific role in the
  spread of HIV impeded by lack of clear
  definition and indicators of concurrency;
• Hence focus of the 20-21 April meeting in
  Nairobi

                                     UNAIDS RST-ESA Johannesburg
       The World Bank Global HIV/AIDS Program (GHAP)




Concurrency – What is it?
Serially monogamous partnerships                           Concurrent partnerships
                                                           1
1
                                                               2
          2
                                                                       3
                            3
                                                                               4
                                              4

                                                       5                             5




time


Same contact rate (5 partners/yr), but sequence of start
and end dates is different
                                         UNAIDS RST-ESA Johannesburg
    The World Bank Global HIV/AIDS Program (GHAP)




Definition of concurrency

Defined as:

“overlapping sexual partnerships where sexual
  intercourse with one partner occurs between
  two acts of intercourse with another partner”

REFER TO ILLUSTRATION

                                      UNAIDS RST-ESA Johannesburg
     The World Bank Global HIV/AIDS Program (GHAP)




Changes we want to measure
• We need more MCP programmes and so we should see
  changes in the HIV community’s priorities and strategies.
• Changing sexual practices in the context of MCP means that
  the sexual networks need to be broken, therefore we should
  see changes in individual behaviours towards fewer multiple
  and concurrent partnerships (i.e. reduction in prevalence of
  concurrency), or increased harm reduction practices if
  concurrency is practiced.
• Decreasing the acceptability of MCP in communities and
  families – changes in social norms.
• Changes in how societies, communities, families and couples
  act towards each other
                                       UNAIDS RST-ESA Johannesburg
     The World Bank Global HIV/AIDS Program (GHAP)


More MCP programmes, skills to
 deliver and funding for them
                              INPUTS
                                                                      Improved relationships
More people reached with MCP                                   Changed social norms and society
        programmes                                               ‘rules and regulations’ about
                           OUTPUTS                                        relationships
                                                                                        OUTCOMES

                                                               Fewer MCPs – lower prevalence of
                                                                 multiple partners, and lower
                                                               prevalence of concurrent parnters
                                                                                      OUTCOMES

                                                               More harm reduction during MCP
                                                                                        OUTCOMES


                                                                     Fewer new HIV infections
                                                                                         IMPACTS

                                       UNAIDS RST-ESA Johannesburg
       The World Bank Global HIV/AIDS Program (GHAP)


Indicators with which to measure the
changes: INPUTS
•   percent of HIV funding spent on prevention (all prevention efforts, as opposed to
    treatment, care, impact mitigation and response management) [NASA]
•   percent of HIV prevention funding spent on behaviour and social change
    communication programmes [NASA]
•   number of policies and strategies relating to HIV that specifically address MCP as
    a key focus area for the HIV prevention response in the country [National
    composite policy index section of the UNGASS reporting processes]
•   percent of HIV implementers trained to implement programmes addressing MCP
    [Programme monitoring data]
•   percent of existing prevention intervention guidelines (VCT, PMTCT, STI, life
    skills, workplace programmes) that have incorporated MCP [Programme
    monitoring data]
•   number of research activities that address MCP programmes [Programme
    monitoring data]

                                         UNAIDS RST-ESA Johannesburg
     The World Bank Global HIV/AIDS Program (GHAP)


Indicators with which to measure the
changes: OUTPUTS
• number of mass media spots that address MCP
• percent of members of cabinet that have addressed MCP in public
  speeches of national interest
• number of people reached with mass media activities focusing on MCP
• percent of community-based organisations with programmes that address
  MCP behaviour for couples in relationships
• number and percent of community leaders trained in MCP
• number and percent of communities in which inter-personal
  communication (IPC) programmes relating to MCP (including family unit
  strengthening programmes) have been implemented
• number and percent of people who have been reached with behaviour
  change communication programmes relating to MCP through
  interpersonal communications (disaggregated by sex and age group)
                                       UNAIDS RST-ESA Johannesburg
      The World Bank Global HIV/AIDS Program (GHAP)


Indicators with which to measure the
changes: OUTCOMES AT INDIVIDUAL & COUPLE LEVEL
Changes in individual knowledge:
• percent of men and women who can correctly identify the increased risks
  associated with MCP
• percent of men and women who can correctly identify the behavioral changes that
  would minimise risk associated with MCP

Changes in individual attitudes
• percentage of men and women who think that MCP is acceptable
• percentage of men and women who think that men/women who are not married
  and are having sex should have sex with only one partner
• percentage of men and women who think that men/women should only have sex
  with their wives/husbands
• percentage of men and women who intend to have multiple partners
• percentage of men and women who discuss MCP with others
                                        UNAIDS RST-ESA Johannesburg
       The World Bank Global HIV/AIDS Program (GHAP)


Indicators with which to measure the
changes: OUTCOMES AT INDIVIDUAL & COUPLE LEVEL
Changes in individual behaviour:
• percent of men and women having multiple partnerships - PREVALENCE OF MULTIPLE
   PARTNERSHIPS
• percent of men and women whose partners have multiple partnerships
• percent of men and women having concurrent partnerships – PREVALENCE OF
   CONCURRENT PARTNERSHIPS
• percent of men and women whose partners have concurrent partnerships
• percent of young women 15 – 19 who had a first sexual partner who was 5 years or more
   older, and 10 years or more older
• percent of men and women with multiple partners who have reported consistently using a
   condom during last sex with non-marital, non-cohabiting partner


                                         UNAIDS RST-ESA Johannesburg
       The World Bank Global HIV/AIDS Program (GHAP)


Indicators with which to measure the
changes: OUTCOMES AT INDIVIDUAL & COUPLE LEVEL
Changes in how couples relate to each other and in relationships
• percent of men and women in steady relationships who report that they have discussed
   their relationship values and agreed on safe sexual practices such as mutual monogamy
   or consistent condom use
• percent of men and women who have a spouse/partner who works away from home and
   is not co-resident for more than 6 months of the year
• percent of young men and women who are married




                                         UNAIDS RST-ESA Johannesburg
       The World Bank Global HIV/AIDS Program (GHAP)


Indicators with which to measure the
changes: OUTCOMES AT COMMUNITY & SOCIETY LEVEL
•   percent of men and women who believe that a woman is justified in insisting on condom
    use if she knows her partner has another sexual partner
•   percentage of men and women who believe a woman is justified in refusing to have sex
    with her husband/partner when she knows that he has had sex with another woman (or
    woman other than his wives, in the case of polygamy)
•   percentage of men and women who believe it is acceptable in the community for a man to
    have multiple sexual partners
•   percentage of men and women who believe it is acceptable in the community for a
    woman to have multiple sexual partners
•   percentage of men and women who believe that MCP is common in the community



                                         UNAIDS RST-ESA Johannesburg
   The World Bank Global HIV/AIDS Program (GHAP)


Indicators with which to measure the
changes: IMPACTS
• Reduced HIV incidence




                                     UNAIDS RST-ESA Johannesburg
   The World Bank Global HIV/AIDS Program (GHAP)




Main uncertainty about indicators for
concurrency, is how to define the
prevalence of concurrency

THEREFORE, the rest of the presentation will
focus on this aspect of MCP measurement




                                     UNAIDS RST-ESA Johannesburg
      The World Bank Global HIV/AIDS Program (GHAP)


Measurement of the Prevalence of
Concurrency
Two main indicators agreed on at meeting in Nairobi:

1. Primary indicator – Point prevalence of concurrency

“The proportion of adults aged 15 to 49 reporting more than one on-going
   sexual partnerships at an instant in time”

• This is to be used as the main indicator of concurrent partnerships in a
  population;
• It also best distinguishes between concurrency and rapid serial
  monogamy


                                        UNAIDS RST-ESA Johannesburg
       The World Bank Global HIV/AIDS Program (GHAP)


Measurement of the Prevalence of
Concurrency
2. Secondary indicator - cumulative prevalence of concurrency:

“The proportion of adults aged 15 to 49 reporting overlapping
   partnerships over time (typically 12 months)”

•   It measures the intensity of exposure
•   Focuses on and can determine the duration of overlap
•   Provide data about the frequency of sex with each partner
•   Does not measure the rate of partner change (partner change rates
    that resemble ABABABABAB is epidemiologically more risky than
    partner change that resemble AAAABBBBBBBB (maybe due to
    migration and temporary separation))


                                         UNAIDS RST-ESA Johannesburg
    The World Bank Global HIV/AIDS Program (GHAP)




To measure these two indicators, need to
ask 3 questions (about each partner)
  When was the first time you had sex with this person?
   (cumulative prevalence and intensity)
  When was the last time you had sex with this person?
   (cumulative prevalence and intensity)
  Are you still having sex with this person? (momentary degree
   distribution, which is the point prevalence)




                                      UNAIDS RST-ESA Johannesburg
 The World Bank Global HIV/AIDS Program (GHAP)




Measurement Methods




                                   UNAIDS RST-ESA Johannesburg
   The World Bank Global HIV/AIDS Program (GHAP)


Measurement Methods
Now that we know what to measure, the next
  question is, how do we measure it?
• Proxy measure
• Direct question method
• Date method
• Coital diaries
• Partner‟s concurrency


                                     UNAIDS RST-ESA Johannesburg
   The World Bank Global HIV/AIDS Program (GHAP)

Using the Date Method - ‘Typical’ Sexual
Behaviour Questionnaire
Have you ever had sex?
General behaviour questions:
     Age at first sex
     Marriage
Counts of partners
     Lifetime, past year, past month
     New partners
„Name Generator‟ (Morris 2004)
     Last X partners in Y duration
     Stratified by partner type?
„Name Interpreters‟ (Questions about each partner)
     Dates/duration of first and last sex
     Partnership type (Marriage, steady, casual, one-time etc.)
     Condom usage & coital frequency
     Partner characteristics: age, location, sexual behaviour (other partners)
     Partnership characteristics: type (spouse, casual, one-time, etc.),
       transactional, coerced, alcohol/drug use

                                     UNAIDS RST-ESA Johannesburg

                                                                                  21
   The World Bank Global HIV/AIDS Program (GHAP)


Identifying Concurrent Partnerships (1)
• Proportion of individuals where start and end dates of previous X
  partners overlap [in last Y duration]
       Name generator + Date (MM/YYYY) of first and last sex with
         each partner
       Name generator + duration since last sex (in
         days/weeks/months) + duration since partnership began
         (weeks/months/years)
 Gives detailed network data
 Sensitive to recall bias for dates/durations




                                     UNAIDS RST-ESA Johannesburg

                                                                   22
   The World Bank Global HIV/AIDS Program (GHAP)


Identifying Concurrent Partnerships (2)
Number of current ongoing partnerships > 1
           Single question: How many sexual partnerships do you
            consider yourself to currently be in?
           Name generator + “Is this partnership ongoing?” or “Do
            you plan to have sex with this person again”
       Measures presence of stable partnerships
       Misses once-off & short partnerships (is this “concurrency”?)
       Identifies momentary degree distribution, less indicative of
        individual risk behaviour?
       Reduces gender differences in # of partners?




                                     UNAIDS RST-ESA Johannesburg

                                                                   23
   The World Bank Global HIV/AIDS Program (GHAP)


Identifying Concurrent Partnerships (3)
Proportion ever had another sex partner during current/most recent
   partnership [in the last Y duration]
       Are you currently in a relationship? + Have you had sex
        with any other person since you began this relationship?
       Name generator + “During this relationship did you have
        sex with any other person” or “During the past year within
        this relationship did you have sex with any other person”
    More exposure to “concurrency” in longer relationships
    Does not distinguish once-off encounters from long-term
     overlapping partnerships




                                     UNAIDS RST-ESA Johannesburg

                                                                   24
  The World Bank Global HIV/AIDS Program (GHAP)


Identifying Concurrent Partnerships (4)
• Proportion reporting > 1 partner in last month
        How many people have you had sex with in the past
         month?
        Name generator + “How many times have you had sex
         with this person in past month?”
 Does not guarantee strict concurrency
 Alternate estimate of degree distribution
 Compared to (2) more likely to include short or once-off
  partnerships




                                    UNAIDS RST-ESA Johannesburg

                                                                  25
        The World Bank Global HIV/AIDS Program (GHAP)


Novel interview methods
↑Privacy & confidentiality
     Self-administered questionnaire (SAQ)
        Feels more confidential
              Issues: Literacy, skip patterns, patience!
     Assisted self-completion questionnaire (ASCQ)
        Interviewer only reads questions/answers but don’t record them
     Computerised
        Audio/Computer assisted self interviewing (A/CASI)
        Palm top assisted self interviewing (PASI, PDA)
              Confidentiality, reduce entry errors
                   Issues: new technologies,
     Non computerised methods
        Tape recorder
        ICVI
        PBS
No gold standard

                                          UNAIDS RST-ESA Johannesburg
Illustration
   The World Bank Global HIV/AIDS Program (GHAP)




           ICVI voting box                              PBS polling box




 Clipboard with enclosed PDA                       Self reported coital diaries
         The World Bank Global HIV/AIDS Program (GHAP)



 Importance of Interviewing Technique:
 Swaziland
Percent reporting 1, 2, 3 partners in
the last 3 months – 2006 (Ngudzeni
ADP)
                                                                             2006-07 Swaziland DHS
            1                2                3                              (nationally)

Male        42.2             32.9             11.8                           • Females reporting more than
                                                                             one partner in the last 12
Female      36.3             58.8             2.9                            months: 2.3%

                                                         Sources: James, V. and R. Matikanya (2006). Protective Factors: A Case Study for
                                                         Ngudzeni ADP (Swaziland), World Vision Australia/Swaziland.; Central Statistical Office
                                                         [Swaziland] and ORC Macro (Unpublished). Swaziland Demographic and Health Survey,
                                                         2006-2007. Calverton, Maryland, Central Statistical Office and ORC Macro.


                                           UNAIDS RST-ESA Johannesburg
    The World Bank Global HIV/AIDS Program (GHAP)



Some breakthroughs at Nairobi Meeting
• Concurrency reporting, in some cases,
  increases threefold, when using different data
  collection methods (voting boxes vs FTFIs);
• HIV is higher among migrant populations, as
  well as those that report having concurrent
  partners (or whose partners report having
  concurrent partners);
• A study in northern Tanzania (Kisesa) is showing
  some behaviour change;

                                      UNAIDS RST-ESA Johannesburg
    The World Bank Global HIV/AIDS Program (GHAP)



Where to next?
• A community randomised trial („break the
  network‟ BCC interventions vs. standard HIV
  messaging) planned for 2010

• PSI and others are currently planning
  evaluations on MCP (Botswana &
  Mozambique); Namibia too



                                      UNAIDS RST-ESA Johannesburg
    The World Bank Global HIV/AIDS Program (GHAP)



Additional areas of research
• Further research into methods of measuring concurrency and
  sexual behavior, relationship between concurrency and HIV
  transmission and social norms and concurrent partnerships;

• The need to continue measuring these behavioral aspects
  through population-based surveys*

• These are also very useful to collect self-reported behavior on a
  large enough scale;

• Need for more in-depth data gathering and that these should
  be triangulated with each other and with survey data

                                      UNAIDS RST-ESA Johannesburg
The World Bank Global HIV/AIDS Program (GHAP)




                                                end


                                  UNAIDS RST-ESA Johannesburg

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:11/6/2011
language:English
pages:32