Perceived, anticipated and experienced stigma: exploring manifestations and implications for young people's sexual and reproductive health and access to care in North-Western Tanzania

This work was conducted under the HPP, a five-year cooperative agreement supported by United States Agency for International Development [grant number AID-OAA-A-10-00067]

Is transactional sex exploitative? A social norms perspective, with implications for interventions with adolescent girls and young women in Tanzania

Although transactional sex is common in many sexual relationships, there has been little research into the degree to which the practice is considered exploitative in the settings in which it is practiced. We describe the social norms that influence transactional sex in two sites in Mwanza, Tanzania, and explore local understandings of whether and under what conditions it is considered exploitative. We then compare these "emic" understandings of exploitation to international definitions and norms around sexual exploitation. This study employed a qualitative research design involving 18 focus group discussions and 43 in-depth interviews with young people aged 14-24 years and parents with children aged 14-24 years in a rural area and an urban center within Mwanza, Tanzania. Thematic analysis was conducted with the aid of NVivo 10. The social norms influencing the practice of transactional sex included: reciprocity as a core cultural value that permeates the way exchange in sexual relationships is judged; gendered expectations that men should provide for women's material needs in sexual relationships and that women should reciprocate by means of sex; and peer pressure to be perceived as "fashionable". Adolescent girls and young women (AGYW) are under strong peer pressure to conform to a "modern lifestyle" as reflected in stylish clothing and other items of modernity such as cellphones. The emic conceptualization of exploitation is defined by circumstances surrounding the relationship or a sexual encounter. Important factors that characterize local notions of when transactional relationships are considered exploitative include: when the encounter or relationship involves an imbalance of power (based on age, male economic power and social status); when a man fails to reciprocate; and when sex is coerced. According to community perspectives, young women's behavior should be considered exploitative of men when they take gifts or money yet refuse sex or when they demand large sums of money. Interventions aimed at reducing AGYW's exploitation through transactional sex need to be cognizant of the variations in the understanding of what constitutes sexual exploitation as well as the social and gender norms influencing the practice of transactional sex. Interventions need to involve communities and families in critical thinking that helps them identify positive alternatives to current gendered social norms that shape the involvement of AGYW and men in transactional sex

'I trap her with a CD, then tomorrow find her with a big old man who bought her a smart phone'. Constructions of masculinities and transactional sex: a qualitative study from North-Western Tanzania

Men’s role in transactional sex is relatively unexplored, limiting initiatives to prevent exploitative transactional sex and its negative health implications for girls and women. We addressed this literature gap by conducting eight focus group discussions and twenty in-depth-interviews with boys and men aged 14 − 49 years in 2015 in Tanzania. We employed a novel combination of theoretical perspectives – gender and masculinities, and social norms – to understand how transactional sex participation contributes to perpetuating gendered hierarchies, and how reference groups influence men’s behaviour. Findings signal two gender norms that men display within transactional sex: the expectation of men’s provision in sexual relationships, and the expectation that men should exhibit heightened sexuality and sexual prowess. Adherence to these expectations in transactional sex relationships varied between older and younger men and created hierarchies among men and between men and women and girls. We found that approval of transactional sex was contested. Although young men were likely to object to transactional sex, they occupied a structurally weaker position than older men. Findings suggest that interventions should employ gender synchronised and gender transformative approaches and should prioritise the promotion of alternative positive norms over preventing the exchange of gifts or money in relationships

How long-distance truck drivers and villagers in rural southeastern Tanzania think about heterosexual anal sex: a qualitative study

Objective: To explore ideas of truck drivers and villagers from rural Tanzania about heterosexual anal sex (HAS) and the associated health risks. Methods: Qualitative study using 8 in-depth interviews (IDIs) and 2 focus group discussions (FGDs) with truck drivers and 16 IDIs and 4 FGDs with villagers from the Morogoro region. Study participants included 24 women and 46 men. Data analysis was performed thematically employing standard qualitative techniques. Results: Reasons why men would practice HAS included sexual pleasure, the belief that anal sex is safer than vaginal sex, alternative sexual practice, exploration and proof of masculinity. Reasons why women would practice HAS included financial need, retaining a partner, alternative for sex during menses, pregnancy prevention and beauty enhancement because HAS is believed to ‘fatten the female buttocks’. Most participants believed that condoms are not needed during HAS. This was linked to the ideas that infections only ‘reside in wet places’ (vagina) and that the anus is not ‘conducive’ for condom use; condoms reduce ‘dryness’ and ‘friction’ (pleasure) and may ‘get stuck inside’. Conclusions: The study participants reported practices and ideas about HAS that put them at risk for HIV and sexually transmitted infections. Greater attention to education about HAS is urgently needed in Tanzania, where this sexual practice is still regarded as a taboo. This study offers useful information that could be included in sex education programmes

Community perspectives on the extent to which transactional sex is viewed as sexual exploitation in Central Uganda.

BACKGROUND: Definitions of child sexual exploitation vary. Sexual exploitation violates children's rights and exposes them to mental and physical harm. There exist differences in views of behaviour that is considered exploitative, including transactional sex. This paper explores community perspectives on the extent to which transactional sex is considered exploitative. METHODS: In 2014, we conducted 19 focus group discussions and 44 in-depth interviews with young people and adults in two communities in Uganda. Participants were presented with vignettes describing sexual encounters between adolescent girls and young women and men to explore under what conditions participants considered the scenario to be exploitative and why. Interviews were conducted in Luganda using a semi-structured tool, audio recorded and transcribed verbatim. Analysis was thematic and complemented by constant comparison and deviant case analysis techniques. RESULTS: Definitions by multilateral, bilateral, and non-governmental organisations of the sexual exploitation of children shared similarities with community conceptualisations of wrong or unfair sex. Although in community conceptualisations there was no consensus on what constituted sexual exploitation, transactional sex was condemned to the extent to which it involved sex with a minor or misled a naïve or immature girl; involved lack of consent, particularly in relationships characterised by power differentials; or worsened the pre-existing status of the girl. Also relevant was the extent to which a man's intentions were considered inappropriate; the adolescent girl or young woman was considered vulnerable; and the adolescent girl or young woman was considered responsible for 'her situation'. CONCLUSIONS: Existing social norms that condemn sex with a minor or sex that involves deception, sexual coercion or misleading an immature girl, present opportunities to mobilise communities to protect adolescent girls and young women at risk. Any intervention must, however, be designed with full cognisance of the social and structural drivers that underlie transactional sex and limit adolescent girls' and young women's opportunities to provide for themselves without recourse to sexual relationships with men. Interventions must also be designed to recognise that girls in transactional sex relationships may not consider themselves as exploited, thus requiring engagement with them based on their own concerns, aspirations, and expectations

Changing forms of HIV-related stigma along the HIV care and treatment continuum in sub-Saharan Africa:A temporal analysis

Objectives Stigma remains pervasive for people living with HIV (PLHIV) in sub-Saharan Africa, undermining care engagement. Using everyday, biographical and epochal temporalities, we explored the manifestation of stigma at different stages of the HIV care continuum in seven health and demographic surveillance sites in Eastern and Southern Africa. Methods Between 2015 and 2016, we conducted qualitative in-depth interviews with 264 PLHIV, 54 health providers and 48 family members of people who had died from HIV. Topic guides explored experiences of HIV testing, care and treatment services. Data were analysed thematically, aided by NVivo 10. Results In everyday time across these communities, stigma was evident in the presence of gossiping and the relative absence of supportive interpersonal discourse, which fuelled judicious disclosure. This was especially disruptive at testing, counselling and early antiretroviral therapy adherence stages of care. Biographical time framed everyday stigma events, highlighting the dilemma of disclosure in relation to sexual relationship norms, as well as the interfacing of age and healthcare continuum points. Epochal patriarchal relations gave a structural context to everyday and biographical stigma dynamics. Historical shifts to social acceptance of PLHIV within these communities, while positive, were complicated by stigma in everyday life and in respect of biographical goals like having a family. Moreover, low community-level resistance to HIV-related stigma jeopardised stigma reduction strategies. Conclusions Despite improvements to HIV care services, stigma remains pervasive across the HIV care continuum in these sites. Context-specific interventions are needed to address stigma and discrimination of PLHIV within the community and in health services, and greater reflection is required to ensure policies aiming to expand HIV treatment do not exacerbate stigma and result in negative HIV outcomes

Changing forms of HIV-related stigma along the HIV care and treatment continuum in sub-Saharan Africa: a temporal analysis.

OBJECTIVES: Stigma remains pervasive for people living with HIV (PLHIV) in sub-Saharan Africa, undermining care engagement. Using everyday, biographical and epochal temporalities, we explored the manifestation of stigma at different stages of the HIV care continuum in seven health and demographic surveillance sites in Eastern and Southern Africa. METHODS: Between 2015 and 2016, we conducted qualitative in-depth interviews with 264 PLHIV, 54 health providers and 48 family members of people who had died from HIV. Topic guides explored experiences of HIV testing, care and treatment services. Data were analysed thematically, aided by NVivo 10. RESULTS: In everyday time across these communities, stigma was evident in the presence of gossiping and the relative absence of supportive interpersonal discourse, which fuelled judicious disclosure. This was especially disruptive at testing, counselling and early antiretroviral therapy adherence stages of care. Biographical time framed everyday stigma events, highlighting the dilemma of disclosure in relation to sexual relationship norms, as well as the interfacing of age and healthcare continuum points. Epochal patriarchal relations gave a structural context to everyday and biographical stigma dynamics. Historical shifts to social acceptance of PLHIV within these communities, while positive, were complicated by stigma in everyday life and in respect of biographical goals like having a family. Moreover, low community-level resistance to HIV-related stigma jeopardised stigma reduction strategies. CONCLUSIONS: Despite improvements to HIV care services, stigma remains pervasive across the HIV care continuum in these sites. Context-specific interventions are needed to address stigma and discrimination of PLHIV within the community and in health services, and greater reflection is required to ensure policies aiming to expand HIV treatment do not exacerbate stigma and result in negative HIV outcomes

Cash plus: exploring the mechanisms through which a cash transfer plus financial education programme in Tanzania reduced HIV risk for adolescent girls and young women

Introduction: Cash transfers have been promoted as a means to reduce HIV risk for adolescent girls and young women (AGYW) in sub-Saharan Africa. One of the main mechanisms whereby they are hypothesized to reduce risk is by deterring transactional sex. In this paper, we use qualitative methods to explore participant experiences, perspectives and reported behaviours of a cash transfer plus financial education programme among out of school, 15- to 23-year-old AGYWs in rural Tanzania with a focus on partner choice and transactional sex. Methods: We conducted 60 in-depth interviews (IDIs) and 20 narrative timeline interviews with participants of the PEPFAR DREAMS Sauti/WORTH+ cash transfer programme between June 2017 and July 2018. Interviews were taped, transcribed and translated from Kiswahili to English. Transcripts were coded and analysed for key themes. Results: We found that participants in a cash transfer plus programme discussed behaviours that could reduce HIV risk through decreasing their dependence on male sex partners. There appeared to be two main mechanisms for this. One, young women discussed the cash transfer providing for basic needs (e.g. food, toiletries) which appeared to reduce their dependence on male sex partners who previously provided these goods (e.g. transactional sex). This experience was more pronounced among the poorest participants. Two, young women discussed how the financial education/business development aspect of the programme empowered them to refuse some sex partners; unmarried women discussed these experiences more than married women. Social support from family and programme mentors appeared to strengthen young women's ability to successful start businesses, produce income and thus be less dependent on partners. Conclusions: The cash transfer programme may have reduced AGYW engagement in transactional sex that occurred to meet basic needs (one form of transactional sex). The financial education/business development and mentorship elements of the programme appeared important in building AGYW agency, self-esteem and future orientation which may support AGYWs in refusing unwanted sex partners. Future cash plus programmes should consider adding or strengthening financial education and job skills training, mentorship and future orientation to see stronger and perhaps sustainable outcomes for HIV prevention

The rebellious man: next-of-kin accounts of the death of a male relative on antiretroviral therapy in sub-Saharan Africa

The HIV response is hampered by many obstacles to progression along the HIV care cascade, with men, in particular, experiencing different forms of disruption. One group of men, whose stories remain untold, are those who have succumbed to HIV-related illness. In this paper, we explore how next-of-kin account for the death of a male relative. We conducted 26 qualitative after-death interviews with family members of male PLHIV who had recently died from HIV in health and demographic surveillance sites in Malawi, Tanzania, Kenya, Uganda, Zimbabwe and South Africa. The next-of-kin expressed frustration about the defiance of their male relative to disclose his HIV status and ask for support, and attributed this to shame, fear and a lack of self-acceptance of HIV diagnosis. Next-of-kin painted a picture of their male relative as rebellious. Some claimed that their deceased relative deliberately ignored instructions received by the health worker. Others described their male relatives as unable to maintain caring relationships that would avail day-to-day treatment partners, and give purpose to their lives. Through these accounts, next-of-kin vocalised the perceived rebellious behaviour of these men, and in the process of doing so neutralised their responsibility for the premature death of their relative