HIV/AIDS Behavioural Surveillance Survey (BSS) Dukwi Refugee Camp, Botswana May 2013 UNHCR & Botswana Ministry of Health 1 Acknowledgements The 2012 Botswana Behavioural Surveillance Survey (BSS) was a joint effort of UNHCR and the Botswana Ministry of Health, with funding from UNAIDS and WHO, and the support of Botswana Red Cross Society. The BSS was initiated and coordinated by Ms. Marian Schilperoord of UNHCR Geneva, and Dr. Njogu Patterson of UNHCR Pretoria, whose depth of experience overseeing similar surveys was incredibly valuable. Dr. Emmanuel Baingana of UNAIDS and Dr. Eugene Nyarko of WHO lent invaluable advice and support during critical phases of the project, and we are exceptionally grateful. The investigation team was led by the Principal Investigator Ms. Aimee Rose who managed the adaptation of the protocol and tools, field work, analysis and reporting. Dr. Marina Anderson, Co‐ Principal Investigator from the Ministry of Health, provided excellent technical oversight and coordination with the Ministry of Health. Three Investigators from the Ministry of Health, Ms. Lumba Nchunga, Ms. Betty Orapeleng and Ms. Bene Ntwayagae, provided input in each phase of the survey, from protocol development, pre‐planning missions to Dukwi Camp, monitoring of training and field work, and report compilation. The team benefitted from the dedicated support of UNHCR Country Representative Lynn Ngugi. We give special appreciation to UNHCR Program Officer Galefele Beleme for her tireless work on recruiting, finance, and logistics, and numerous other issues. UNHCR Head of Field Office Jane Okello facilitated the survey’s success at Dukwi Camp, with superb assistance from UNHCR staff Niroj Shrestha, Gracias Atwine, and Onkemetse Leburu. The Botswana Red Cross Society (BRCS) was an important part of the BSS, from design to implementation. We pay special thanks to Tshepo Garethata, Project Coordinator, for her consistent support of the project, and to the entire BRCS team, including Dr. Masego Gilbert‐Lephodisa, who facilitated the pre‐planning mission and provided invaluable information on the clinic’s services. The BRCS has an incredible group of refugee volunteers, and we were lucky to have the assistance of 19 of them during the survey period. They helped the survey team mobilize the community, navigate the camp, and keep track of our progress. The efforts of our survey team were exceptional. We thank the Survey Coordinator, Keletso Moruti, the 20 interviewers, and the 3 data entry clerks, all of whom worked long hours to make the survey a success. We also thank the 357 men and women at Dukwi Refugee Camp who generously shared their time and experiences with us during the interview process. The efforts of all field staff and participants are greatly appreciated. 2 Executive summary This report describes the findings of the first Behavioural Surveillance Survey (BSS) among refugee populations in Botswana, which was conducted as a joint effort of UNHCR and the Botswana Ministry of Health. The survey was designed to examine the current prevalence of HIV related behavioural risk factors and vulnerabilities among residents of Botswana’s only refugee camp. Data was collected between September 24 and October 2, 2012 in Dukwi camp, located 130 km from Francistown, Botswana. Objectives The main objectives of the Botswana BSS were to: 1. Estimate the current prevalence of key risk, protective, and preventive behaviours and vulnerabilities known to be associated with HIV infection, among refugees living at Dukwi Camp 2. Determine socio‐demographic characteristics associated with current key risk, protective, and preventive behaviours, among refugees living at Dukwi Camp 3. Describe interactions between refugees and surrounding host populations 4. Establish a baseline to enable future BSSs to measure changes in key risk, protective, and preventive behaviours. Methodology: The BSS was an observational, cross‐sectional behavioural survey, which was planned and implemented according to UNHCR’s guidelines for conducting such surveys among displaced populations. Systematic random sampling was done to select houses for participation. People aged 15 – 49 years living in selected houses in the camp were eligible to participate. Trained interviewers screened for eligibility, obtained consent of participants and administered a standardized BSS questionnaire. Main findings: The BSS included 172 refugee men and 185 refugee women from 10 countries, with the greatest numbers from Namibia (37.8%), Zimbabwe (34.2%), and Angola (13.5%). More than half the population has lived at Dukwi Camp more than 5 years. Main findings include: A sizeable segment of the Dukwi population is highly mobile. Refugees who are mobile are difficult to include in HIV surveillance exercises such as this one, and difficult to reach with services. Overall, awareness and knowledge of HIV was fairly high among respondents interviewed in the camp. Compared to older respondents, fewer youth had comprehensive knowledge about HIV. Among respondents who had had sex, youth were more likely than older respondents to have used a condom. 3 Twenty one percent of youth who had not had sex did not know where to obtain a condom. Most respondents support the idea of teaching adolescents about condoms. While marriage was associated with fewer reports of multiple partnerships, there was no difference between never married respondents who were living with a sexual partner and those who were not living with a sexual partner. Recent transactional sex was rarely reported. While anal sex was not widely reported, 4.4% of women reported recent anal sex, and fewer than half used a condom. Less than a quarter of male respondents reported that they had been circumcised. Among those who had not been circumcised, more than half were interested in safe male circumcision. Most respondents have been reached with HIV information. Recent HIV testing was common, at rates comparable to those in greater Botswana. Almost 97% of respondents said they knew a place where HIV/AIDS treatment can be obtained. Recommendations: After the study results were finalized, UNHCR convened a workshop to review the findings and formulate recommendations. Ministry of Health representatives from various departments attended, along with key staff from UNHCR, UNAIDS, and the Botswana Red Cross Society. Together, the group developed recommendations. A few key recommendations include: Steps should be taken to align HIV services for refugees with the government program. Adherence in the ART program is one potential example of gaps in the system. The encampment policy may drive refugees to take jobs far away from the camp, and it exposes them to the risk of incarceration, which is itself linked to increased risk of HIV transmission. This policy should be reviewed. Staff must design interventions to reach highly mobile groups. Coordinating with the vocational training center may be one strategy to reach youth with HIV prevention messages. Another strategy is to focus on programming for younger, school‐age adolescents to ensure that they will have knowledge as they get older. Prevention programs should emphasis faithfulness with partners, whether married or living together. Introduction of safe male circumcision at Dukwi Clinic should be considered, and more information on current circumcision practices is needed. Reported unavailability of condoms points to the need to identify the bottlenecks and improve availability of condoms in the camp. The finding that transactional sex is not commonly reported is inconsistent with experience of UNHCR and BRCS staff. Given the limitations of surveys, this issue may deserve further consideration using qualitative research approaches. While anal sex was not commonly reported, those who practice it should be getting messages about condoms and lubricants. Information must be spread to refute any misconceptions about the risks of anal sex. 4 Finally, it is generally recommended to repeat a BSS every four or five years. In the case of Dukwi Camp, a study which includes both behavioural and biological surveillance is suggested to be conducted in 2014 to establish a baseline of prevalence and incidence of HIV and other STIs, and allow for future analysis of trends in the camp. Furthermore, while the 2013 BAIS has already been planned, it is important to consider including the refugee population in future general population surveys. 5 Table of Contents Acknowledgements ...................................................................................................................................... 2 Executive summary ...................................................................................................................................... 3 Abbreviations and acronyms ..................................................................................................................... 11 Chapter 1: Introduction .............................................................................................................................. 12 Section 1: HIV background ...................................................................................................................... 12 HIV in Botswana .................................................................................................................................. 12 National Response to HIV/AIDS .......................................................................................................... 12 Section