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Demographics of the Sample THE UNIVERSITY OF HULL Steering an AIDS-free Course: Personal Prevention Strategies of Young People in Tanzania being a Thesis submitted in partial fulfilment of the requirements for the Degree of Doctor of Philosophy in the University of Hull by Laurie Lynn Kelly, BSc, MF, PG Dip (Research) September 2012 Abstract This thesis presents an exploration of the personal HIV/AIDS prevention strategies of young adolescents in Tanzania. Most of the 209 research participants were aged 10- 15. They included students, those out of school and ‘street children’. In this multiple method study, the young people participated in focus groups, individual interviews, questionnaires, ranking exercises, and write-and-draw exercises. Most of the participants were motivated to prevent HIV/AIDS and were able to communicate credible strategies. Many participants described tactics related to refraining from sex. Males tended to describe sexual temptation in terms of their own sexual desires, and refraining from sex in terms of the management of those desires. Females tended to describe sexual temptation in terms of the benefits males might offer in exchange for sex and the possible risks of agreement or refusal. Females described refraining from sex in terms of politely refusing, eluding and outsmarting males, and avoiding situations where rape might occur. Male participants who discussed penile-anal sex nevertheless seemed to associate HIV transmission mainly with heterosexual relationships and penile-vaginal sex. In further findings, many participants described tactics related to the prevention of blood-borne infection. Some participants mentioned testing and transmission in mother-to-child and caring relationships. Although most participants agreed in theory that condoms were a good way to prevent HIV/AIDS and that it was acceptable for a male or female to ask a partner to take an HIV test before having sex, relatively few participants included testing or condoms in their strategies. Most pilot study participants were knowledgeable about some aspects of prevention, but demonstrated no knowledge of HIV prevalence. This study indicates a role that national and international leaders, policy makers, teachers, parents and others might play to encourage young adolescents to steer an AIDS-free course, by supporting young people to build on their existing personal strategies of prevention, and to develop and adapt their strategies as they mature. That may support the young people to delay the sexual debut, to prevent HIV/AIDS when beginning and maintaining sexual relationships, to refrain from sex, if they wish, after the sexual debut, and to reduce the incidence of blood-borne transmission, mother-to-child transmission, and transmission when caring for others who may be affected. Table of Contents Abstract .................................................................................................... 2 Abbreviations and Acronyms ................................................................. 14 Acknowledgements ................................................................................ 16 1 Introduction ..................................................................................... 18 1.1 The Challenge of Message-based Interventions ....................................... 18 1.2 HIV/AIDS Prevention Research Concerning Young Adolescents in Tanzania and the Region ....................................................................................... 24 1.3 Research Questions ................................................................................... 26 1.4 Structure of the Dissertation ..................................................................... 26 2 The Context of HIV/AIDS in Tanzania .......................................... 28 2.1 Demographics of the Epidemic ................................................................. 28 2.2 Systems of Knowledge and Understanding .............................................. 30 2.3 Stigma and Denial ..................................................................................... 38 2.4 HIV/AIDS Prevention through the Life Course........................................ 43 2.4.1 Virginity and Abstinence .................................................................. 43 2.4.2 Sexual Debut ..................................................................................... 44 2.4.3 Intergenerational and Transactional Sex ........................................... 44 2.4.4 Faithfulness and Partner Reduction .................................................. 46 2.4.5 Condoms ........................................................................................... 47 2.4.6 Voluntary Counselling and Testing (VCT) ....................................... 48 2.4.7 Unprotected Anal Sex ....................................................................... 48 2.4.8 Marriage, Early Marriage and Polygynous Marriage ....................... 49 2.4.9 Parenthood ........................................................................................ 50 2.4.10 Widowhood and Dispossession ........................................................ 51 2.4.11 Orphans ............................................................................................. 52 3 2.5 Prevention Programmes and Policy .......................................................... 53 2.5.1 National Prevention Policy and Funding .......................................... 53 2.5.2 Prevention Interventions for Younger Adolescents .......................... 63 2.5.3 Monitoring and Evaluation of Prevention Interventions .................. 65 2.5.4 Encouraging Young People to Take an Active Role ........................ 67 2.6 Conclusion ................................................................................................ 68 3 Strategy and Risk ............................................................................ 70 3.1 Understandings of Strategy ....................................................................... 70 3.1.1 Strategies as Organizational or Individual Endeavours .................... 70 3.1.2 Strategies as Bellicose and Creative Endeavours ............................. 71 3.1.3 Strategies Are Not the Same Thing as Intentions, but Are Relationships between Behaviours and Intentions through Time ........................................... 73 3.1.4 Strategies as Relationships between Means and Ends ...................... 74 3.1.5 Strategy as a Bridge between Structure and Agency ........................ 75 3.1.6 Strategies Employ Tricks, Tactics and Stratagems ........................... 80 3.1.7 Strategies Take Place within Contexts of Power .............................. 82 3.1.8 Strategies Entail Tradeoffs ................................................................ 83 3.1.9 Strategies Can Be (Apparently) Irrational ........................................ 83 3.1.10 Summary of Strategy ........................................................................ 85 3.2 Risk Management ..................................................................................... 86 3.2.1 Structural Drivers of Risk ................................................................. 86 3.2.2 Positivist Approaches to Risk Management ..................................... 88 3.2.3 Ecological Approaches to Risk Management ................................... 92 3.2.4 Social and Cultural Approaches to Risk Management ..................... 94 3.2.5 Summary of Risk .............................................................................. 95 3.3 Empirical Examples of Prevention Strategies and Risk Management ...... 96 3.3.1 Prevention Strategies of Children and Young People....................... 97 4 3.3.2 Prevention Strategies of Women ..................................................... 103 3.3.3 Prevention Strategies of Men .......................................................... 105 3.3.4 Prevention Strategies Common to Men and Women ...................... 109 3.3.5 Non-Strategies ................................................................................. 113 3.4 Conclusion .............................................................................................. 113 4 Methodology ................................................................................. 115 4.1 Introduction ............................................................................................. 115 4.2 Preliminary Conversations and Interviews with Key Adult Informants . 115 4.3 Research Access ...................................................................................... 116 4.4 Research Locations ................................................................................. 117 4.5 Research Assistants ................................................................................. 127 4.6 Participant Recruitment ........................................................................... 130 4.7 Demographic Characteristics of Research Participants .......................... 131 4.8 Design and Conduct of the Research ...................................................... 134 4.8.1 Research Days ................................................................................. 134 4.8.2 Introduction to the Multiple-method Research ............................... 136 4.8.3 Focus Groups .................................................................................. 137 4.8.4 Individual Interviews ...................................................................... 140 4.8.5 Ranking Exercise:
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