Male sexual partners of adolescent girls and young women in Tanzania�- Who are they and how can they be reached?��A synthesis of existing evidence

May 2023

Hi! I am Tobi, your i2i ambassador.

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By partnering with countries to identify cross-cutting HIV prevention evidence gaps, i2i synthesises existing evidence into clear, practical and easily utilised knowledge products.

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These products are effectively implemented through i2i's collaboration with country stakeholders, to ultimately strengthen the HIV prevention response.

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Thank you for joining us today to engage with our relevant evidence-based content to drive and optimise HIV prevention.

Agenda

Chair: Jerry Okal

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Opening Remarks

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Dr. Pedro Saro

Objectives

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Ayesha Ismail

1. To share synthesised and consolidated research on MSP of AGYW in Tanzania

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• To discuss how these findings may impact and influence current and future programmes and policies

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• To understand how Tanzania Country Champions can apply the findings in their spheres of influence

Who are the MSP of AGYW

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Sarah Magni

And how can they be reached?

Content List �

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Useful Acronyms�

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Glossary

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1 | BACKGROUND & PURPOSE

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i2i supports country HIV prevention teams to strengthen their AGYW HIV prevention programming through facilitated learning and application of promising practice

i2i does this by:

Consolidating and synthesising selected HIV prevention research and promising practices to inform key AGYW stakeholders in-country in a way which guides stakeholders on how to apply the findings.

Providing guided support so that country stakeholders can become champions for AGYW facilitated learning.

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Kenya

Malawi

Mozambique

Tanzania

South Africa

Uganda

Zambia

Zimbabwe

Each country has a group of AGYW Country Champions that represent these groups. These individuals serve as the point persons for Sycona

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WE FACILITATED A SERIES OF ACTIVITIES WITH AGYW CHAMPIONS IN TANZANIA IDENTIFY EVIDENCE GATOPS FOR AGYW PROGAMMING IN THE COUNTRY

Country Champions reflected on the barriers AGYW encountered in accessing HIV services using a jam board exercise

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Country Champions completed PSATs which are tools which countries use to assess and monitor their progress towards comprehensive prevention programming.

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We also engaged with other regional initiatives focusing on AGYW

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We held monthly meetings with the Country Champions to validate the evidence gaps

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Jamboard

Exercise

PSAT

Other Initiatives

Validate

One of the key gaps through these processes was a need to better understand the characteristics of male sex partners (MSP) of AGYW and where they could be reached with HIV prevention programming?

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THIS DECK Synthesises and contextualises EXISTING programmatic research ON MSP OF AGYW in TANZANIA. THESE FINDINGS ARE INTENDED TO BE USED TO refine HIV PREVENTION Programming FOR AGYW

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1.

Describe the characteristics of MSP of AGYW

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Describe the motivations for AGYW engaging in sex with different types of MSP

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Document where AGYW meet their MSP

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Describe promising practice(s) in reaching MSP of AGYW

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Inform the design of programming to reach MSP of AGYW

*interactive activity

Specially, this review of research from Tanzania aims to:

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2 | Methods

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We collated the findings from three studies using programmatic data and one study using primary data which were undertaken to understand MSP pf AGYW in the Dreams Partnership in Tanzania

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THE ASERT^TM TOOL IS A METHOD FOR AGYW TO DESCRIBE TYPES OF MSP WITH WHOM THEY HAVE SEX

• The Ascertaining Sexual Relationship Types (ASERT^TM) is an anonymous, group-based reporting method
• It is used with pre-existing groups of AGYW in a safe space to facilitate a discussion about:
• How they rank MSP in their community
• Reasons they have sex with each MSP type

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• The output is a visual representation of types of MSP and reasons for engaging in sex with each type¹

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• ASERT^TM is used to encourage AGYW to reflect on and discuss issues related to HIV risk, social status, and economic survival strategies
• After implementing the ASERT^TM tool, facilitators lead a discussion on the reasons for ranking different MSP
• ASERT^TM was not developed as a research tool

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Figure 1: ASERT^TM tool. Population Council, 2016 and adapted version, HJFMRI, 2018

Figure 2: Small group discussions on typical MSP of AGYW, Sauti 2018 and HJFMRI, 2017

1 ASERT^TM is used to characterise types of MSP on average that AGYW have seen with and not identify specific individual experiences

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STUDY 1

STUDY 3

STUDY 4

STUDY 2

Distribution of the Primary studies locations within Tanzania

We collated the findings from all four existing studies

• We reviewed the presentations and reports from all four studies of MSP of AGYW in Tanzania
• Where primary data were available (study 3 only) we transformed the data using the same coding as for study 2

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STUDY 1

STUDY 2

STUDY 3

STUDY 4

3 | Findings

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1. What are the characteristics of MSP of AGWY?

Each primary study reports on slightly different groups of MSP and the way that these are presented is inconsistent

Although all three primary studies made use of the ASERT™ tool, the results are reported differently, making it difficult to compare and consolidate the characteristics of MSP:

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All three primary studies use a mix of occupations e.g., businessmen as well as ages e.g., older men in characterising MSP

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STUDY 1

STUDY 2

STUDY 3

Reports on 13 types of MSP.

Classified by the motivations for AGYW having sex with them and whether or not they are age-disparate relationships

Categorises MSP into 11 groups and reports on percentages per group and district.

Identifies 25 groups of MSP and describes each group. It also outlines the reasons why AGYW report engaging in sex with each group.

STUDY 1 found that the range of sexual partner types described was broader than previously documented

• 13 different types of MSP were described, although proportions of each were not reported
• These 13 types varied by lifecycle stage, socio-economic status, and potential HIV risk to AGYW
• 9 types were reported by both age groups; 3 were described only by adolescent girls (AG, aged 15-19) and 1 type was distinct to young women (YW, aged 20-24)

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Table 1: Describes the 13 types of MSP reported and demonstrates which groups of AGYW reported each type by age, geographic location and region

Labourers, drivers and businessmen accounted for the majority of MSP described by AGYW in study 2

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• Study 2 found that unskilled labourers, defined as “anyone who didn’t wear a button-down shirt”, made up a quarter of MSP of AGYW

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Figure 3: Distribution of AGYW responses to types of MSP in five districts

n=2,179 (Adapted from Sauti, 2018)

Unskilled labourers: tailors, farmers, fishermen, casual labourers, masons, miners & watchmen

Skilled labourers: bank staff, accountants, doctors, teachers & other employed officers

Drivers: taxi, motorcycle, bus conductor & lorry drivers

State representatives: magistrates, police officers, army officers, village & ward executive officers, councillors &unspecified leaders.

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• The distribution of the top four types of MSP described differed by district in which study 2 took place

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Figure 4: Distribution of top four AGYW responses to types of MSP by district (Adapted from Sauti, 2018)

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Businessmen

*Local business owners and shop keepers

Healthcare workers

*Those who work in the nearby health centers, hospitals & dispensaries

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Teachers

Soldiers and police

Long distance drivers

Builders

Cart operations

Pastors

Permanently employed men

Bajaj, motorcycle (bodaboda) and taxi drivers

IN STUDY 3, AGYW DESCRIBED 25 DIFFERENT TYPES OF MSP

Footballers

Students

*University, college and secondary school students

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Street hawkers

*Includes sellers of fried chips, clothes, CDs, cosmetics, & others

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Sharobaro

*Very smart all the time, new cut styles

Married and older men

Barbers

Using the same coding criteria as a Study 2, labourers, drivers and sellers accounted for the majority of MSP described by AGYW in study 3

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• Drivers comprised 22% of all MSP described.
• Labourers (unskilled 13%, and skilled 12%)
• An additional large category(18%) not present in Study 2 was noted. Sellers comprised those who sold items like clothes (mitumba), fried chips and CDs

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Figure 5: Distribution of AGYW responses to types of MSP in 36 wards

n=315 (Adapted from HJMRI, 2018)

Data transformed using the same categorisations as in Study 2

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Unskilled labourers: barbers, farmers, masons, mechanics, casual labourers

Skilled labourers: doctors, teachers & shopkeepers

Drivers: bajaji drivers, motorcycle drivers, bus conductor & lorry drivers

State soldiers

Peers: Sharobaro, students

• The distribution of the top four types of MSP described differed by age of AGYW

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Figure 6: Distribution of top AGYW responses to types of MSP by age (adapted from HJMRI, 2018)

Using the same coding criteria, comparing Study 2 and Study 3

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Figure 7: Comparison of the Distribution of AGYW responses to types of MSP in five districts (Study 2: Adapted from Sauti, 2018) and Distribution of AGYW responses to types of MSP in 36 wards (Study 3: Adapted from HJMRI, 2018)

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Percentage (%)

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2.What are the motivations for AGYW engaging in sex with different types of MSP?

Study 1 found that AGYWS’ Motivations for engaging in sex differed by each of the 13 MSP identified. Motivations differed by partner age.

• Eight of the 13 types were age-disparate:
• Three age-disparate types of MSP described were purely for access to services or financial assistance (structural motivations)
• The other five types were described as offering mainly structural but also varying degrees of socioemotional benefits
• All five of the same age MSPs described were almost entirely for fulfilling different socioemotional needs and aspirations

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Figure 8: Continuum of socio-economic vs socio-emotional motivations for engaging in sex with different MSP. Adapted from Hallman et al (2017)

Study 2 Identified three broad categories of motivations why AGYW have sex with different mSP: Transaction and materials, individual characteristics and intimacy & Attraction

• Overall transaction and materials accounted for nearly three quarters (74.2%) of the reasons why AGYW reported having sex with MSP
• Money, services and favours were the most commonly reported motivations within this category
• Intimacy and attraction comprised the next most common group of reasons (17.2%) AGYW reported engaging in sex with MSP
• Love and affection was the most commonly reported reason (11%) within this category
• Individual partner characteristics was the least common reason AGYW mentioned for having sex with their MSP
• Within this category, social status was the most common reason accounting for 3.6%

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Figure 9: Distribution of reasons AGYW reported for having sex with MSP, adapted from Sauti, 2018 (n=2,168)

Study 2 also found that the motivation for engaging in sex differed by partner type. Compared to relationships with peers, sportsmen or entertainers, exchange of money was more likely with all other partner types.

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11.0%

3.6%

DISTRIBUTION OF REASONS WHY AGYW HAVE SEX WITH MALE SEXUAL PARTNERS (N= 2,168)

% AGYW SUB-GROUPS WHO STATED REASON

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Study 3 found that the most commonly reported reason for engaging in sex with MSP was for money comprising more than 10,000 Tsh

• After money, the most common reasons included material support and services, followed by sexual satisfaction and physical attributes
• Emotional support was mentioned infrequently as a reason AGYW had MSP
• Larger amounts of money was the most common reason for both AG and YW, but the second most common reason differed. In AG, this was “goods” and in YW, it was “sexual satisfaction”

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Figure 10: Distribution of reasons AGYW reported for having sex with MSP, adapted from HJFMRI, 2018

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3.Where do AGYW meet their MSP?

Studies 1 and 3 did not report where AGYW met their MSP, however Study 2 found that the most common place where AGYW reported meeting their MSP for the first time was neighbourhood streets. Many other meeting places, including different areas where MSP work were also described

• Study 2 also explored where AGYW hung out with their MSP. The three most commonly reported places were:
• Bar of local brewhouse (22%)
• Hotel or guesthouse (20%)
• Kijiweni or “local male hangout” (8%)

• Study 2 found that both unskilled and skilled labourers and drivers comprised the majority of MSP described by AGYW. Figure 11 is consistent with this finding, showing that many MSP are met around transport nodes and places of work.

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Figure 11: Distribution of where AGYW reported first meeting their MSP, adapted from Sauti, 2018 (n=915)

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3. What are the promising practices in reaching MSP of AGYW?

Several promising practices to identify and recruit MSP and to provide them with services. However, it is not always apparent how these are directly related to the study findings

• Use of programmatic assessment tools exist
• ASERT^TM can be used to identify types of MSP, and not just to facilitate discussion

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• Identification and recruitment of male partners
• Index testing/seeds/ partners of AGYW
• Hot spots approach
• Economic strengthening is a useful “hook” to interest men

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• Provision of services
• Fast tracking of men in HIV and AIDS services (Facility navigation and escort system)
• Providing an escort allowance to community service providers for linking HIV positive identified clients
• Extended hours clinics which serves more men who are unable to come during normal working hours
• Addressing confidentiality concerns for men
• Bringing services out of facilities

Study 1 Suggests that HIV programming to reach MSP described should be refocused

The strategy suggested that programming should:

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1. Focus on high-risk men with HIV prevention services such as HIV counselling and testing (HCT)
• But should not do so in a way which shames them e.g., fataki campaigns
• Instead, programming could support alternative ways for men to display their wealth and masculinity. For example, they could provide sponsorship opportunities

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• Target partner types who are attractive to AGYW because of the services they can provide to them possibly through professional associations or existing labour organisations

Figure 12: Distribution indicating that the majority of preventative programs target same-age, lower-risk partners. Adapted from Hallman et al. (2017)

Conventional Programme

Focus

The results from study 2 were used by the IP to undertake route mapping

To reach MSP who have a higher HIV risk, it has been suggested that programmes should specifically target:

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1. Training male CBHSPs to map hotspots in each ward. Hotpots included types of places identified using the ASERT^TM tool such as entertainment sites and workplaces.

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• Undertaking mobile and moonlight testing.

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• Linking men to VMMC and ART programmes

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The IP identified MSP of index AGYW using the partner notification register, although preliminary analysis showed no difference in the HIV positivity yield.

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Figure 13: Example of male hotpot mapping, Sauti, 2018

Figure 14: Partner notification register, Sauti, 2018

STUDY 3 fed into the IP’s strategy to reach msp

The strategy comprised:

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1. Mwanaume Jitambue, a facility and community-based intervention to increase HIV service uptake among men aged 15-35 with high risk of HIV infection

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• Extended HIV clinic services (evening and weekend) to serve more men who are unable to come during normal working hours

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• Index/Partner notification

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Study 4 concluded that Male characterisation study findings partly being used to inform recruitment and inclusion

• Results have been written up but the section on HOW these impact programme is not well articulated

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• At a community partner level, findings are being partly used
• Primarily used to find men at hotspots (i.e. where) e.g. tea plantations, bars, under trees, “parking lots for bodabodas”
• Used for monthly route planning
• Not as useful when strategies like index testing used but “there is a place for both index testing and male partner characterisation”

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• Clinical partners are not aware of the research and so are not using the findings
• However, it needs to be better understood whether these are useful for the clinical partners

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Summary of

findings

Some good information on which to make decisions exists but there is room to improve the understanding of msp of AGYW

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Reasons why AGYW engage in sex with male partners differ, but transactions of some kind play a role in the majority of relationships.

Studies do not report on psychographics of MSP so difficult to characterise beyond age and occupation

Places where AGYW meet their sex partners seem to be quite broad, with many places being reported

Various occupations which appear to location-specific e.g., chip sellers were prominent in Mbeya. Transport workers were prominent across all locations.

Often depicted as older ‘sugar daddies’ in lay publications (i.e., much older than AGYW). This does not appear to be entirely accurate.

Findings not always used beyond where to find men and which occupations to target

4 | Limitations

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There are several limitations to this evidence synthesis

This synthesis relied on existing studies, most of which were out of date

No formal research to characterise MSP has been undertaken, and none with men themselves

Programmatic assessments have been undertaken using ASERT^TM but differences exist in:

• Sample size
• Way in which data is analysed and reported
• Does not appear to be a standardised and easy way to analyse data

ASERT^TM tool: does not provide prevalence estimates of particular sexual partner types; nor are they necessarily applicable to geographic areas outside the study locations

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Q&A Session

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Esther Majani & Hijja Wazee

Recommendations

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Sarah Magni

Recommendations to improve MSP characterization research

• Strengthen programmatic studies to characterise and identify male sex partners of AGYW.

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• Develop a more nuanced understanding of the male sex partners in each country, including their psycho-behavioural characteristics

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• Identify male sex partner population segments based on demographic and psycho-behavioural characteristics. Use more complex analysis, like Latent Class Analysis

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• Estimate population sizes for key male partner segments. This will help with target setting and monitoring

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• Undertake formative research with the key male sex partner segments

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• Present findings in easy-to-use formats that on-the-ground staff can easily understand (e.g., personas)

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• Strengthen dissemination and sharing of results for both the formal research and programmatic studies

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Figure 15: Example of MSP personas, Gottert, 2018

Recommendations to improve….

• Develop capacity for community mapping to improve identification and reach of key segments.
• Develop messages and interventions suited to priority segments of male sex partners, by using male sex partner characterisation findings.
• Improve targeting and inclusion of men who fit the profile of priority segments of male sex partners.
• Establish a multi-dimensional package of services that appeals to men and male sex partners of AGYW.

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MSP targeting & enrolment:

• Explore implementation of centralised, national databases with unique identifiers. Databases could collate data on layered services received by male beneficiaries.
• ͏Develop more distinct targets for priority male sex partner segments
• ͏Evaluate programmatic outcomes and impacts for priority MSP segments.

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MSP programming:

Interactive Activity

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Maria Mensah

5 | What does this mean for programming for MSP of AGYW?

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Mentimeter Questions

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MENTIMETER

Mentimeter Questions

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1. Who are the key partners who can help action each of these recommendations? And how?

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• As a champion how can you move this forward within you sphere of influence? What can you commit to?

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Session Feedback Poll

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Jerry Okal

Mentimeter Questions

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MENTIMETER

Mentimeter Questions

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1. On a scale of 1 to 5, how useful did you find this session?

(1 = Not very useful and 5 = very useful

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2. How likely are you to use the information from this session in your work and/or share it with your colleagues?

(scale of 1 = [Not] to 5 = [Very])

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Closing Remarks

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Dr. Pedro Saro

Thank you

Suggested citation: Insight 2 Implementation: an SLLN offering (2023). Male sexual partners of adolescent girls and young women in Tanzania - Who are they and how can they be reached? A synthesis of existing evidence. Available from www.hivinterchange.com.

REFERENCES

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1. Hallman, K et al. 2017. “Beyond boyfriends and sugar daddies: Ascertaining Sexual Relationship Types (ASERT) among poorly-educated girls and young women in Tanzania.” New York: Population Council

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• Hallman, K et al. N.d. “ASERT TM reveals 13 distinct sexual partner types among adolescent girls and young women in Tanzania.” International AIDS Conference Poster. New York: Population Council

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• Hallman, K.K., Peracca, S., Jenkins, A., Matee, N., Mrisho, F., Paul, P., 2017. Beyond boyfriends and sugar daddies: Ascertaining Sexual Relationship Types (ASERT) among poorly-educated girls and young women in Tanzania. International AIDS Conference Poster

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• HJFMRI. 2018. “HJFMRI Adolescent Girls and Young Women (AGYWs) Sexual Partners Characterization Exercise.” Mbeya: HJFMRI

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• Genesis Analytics. 2019. “Male partner characterisation and inclusion in HIV programmes implemented at DREAMS sites in ten countries”. Johannesburg: Genesis Analytics

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• Genesis Analytics. 2018. “Documentation of male partner characterization and inclusion in HIV prevention programs implemented at DREAMS sites in ten countries: Draft Findings from Tanzania”. Dar es Salaam: Genesis Analytics

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• Gottert. A. 2018. “Men’s HIV risk profiles in South African DREAMS sites: Using latent class analysis for more strategic, context-specific programming and evaluation.” Amsterdam: Population Council

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• Population Council. 2016. "Building Girls’ Protective Assets: A Collection of Tools for Program Design." New York: Population Council.

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• Wazee, H. 2018. “Characterization of Male Sexual Partners.” Mbeya: HJFMRI.

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• Population Council. 2016. "Building Girls’ Protective Assets: A Collection of Tools for Program Design." New York: Population Council.

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• Sauti. 2018. “Characterization of Male Sexual Partners of Vulnerable Out-of-School Adolescent Girls and Young Women Under the Sauti Project in Tanzania.” Dar es Salaam: Sauti.

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• Sauti. 2018. “AGYW Male Partner Characterization: Process and Preliminary Results.” Dar es Salaam: Sauti.

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