HIV PREVENTION WITH ADOLESCENT GIRLS AND YOUNG WOMEN
Adolescent girls and young women in sub-Saharan Africa are at disproportionally high risk of HIV. The risk could be due to multiple factors such as meeting functional and material needs, requiring social affirmation or looking for respect and safety. Often, relationships with men who may be able to meet their goals in the short term become the default route.
Programs that make cash payments to girls and young women and help them develop income-generating skills might seem like a solution. But we suspected that sexual risk behavior is more than just a question of material incentives.
We used our research methods to develop a systematic, comprehensive map of a young woman’s journey toward maturity. We discovered that some lacked a sense of self-agency, and without it, the positive effects of cash transfers would falter once programs ended. For other young women, developing the skills to manage an emotionally healthy relationship with their romantic partner was a more urgent goal than HIV prevention.
With these insights, we were able to propose frameworks for programs to boost self-agency, and give young women the skills to develop healthy relationship habits, so that in the long run they could make safer sexual choices.
Bill & Melinda Gates Foundation
South Africa & Tanzania
HIV Prevention & Cash Transfer
A question with no simple solutions
What puts adolescent girls and young women at such high risk of HIV? It’s a question that researchers, program planners and implementers have been trying to answer for years in sub-Saharan Africa – a region with 11% of the world’s population but 70% of the global burden of HIV.
Adolescent girls and young women are up to 8 times more likely to acquire HIV than boys and young men of the same age
Some of those behavioral drivers have been identified. They include transactional sex (sex in exchange for money or other goods), intergenerational sex (where the male partner is at least seven years older than the girl or young woman), and low rates of consistent use of HIV prevention products. Yet even with this knowledge, programs may struggle to have a significant impact when they fail to treat HIV incidence among adolescent girls and young women as a complex, multifaceted issue – one that can’t be solved simply with a sexual education program or another “one size fits all” solution.
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HIV programs struggle to have impact if they fail to understand that prevention is complex and multifaceted
Final Mile decided to take a multidimensional approach to understanding the HIV epidemic in Tanzania and South Africa – two of the hardest-hit countries in sub-Saharan Africa. We aimed to take into account not just the behaviors of adolescent girls and young women, but their decision-making processes too. We wanted to understand in depth what motivated them to act sometimes in ways that increased their HIV risk, and the barriers that stood in the way of behavior change.
Our strategy recognized that becoming infected with HIV is rarely a straightforward matter, but rather is due to many interdependent factors that influence a person’s behavior. Framing it simply as an issue of risk might lead us to miss critical contextual factors. Likewise, it would be wrong to focus on HIV prevention from a purely medical point of view – there are other factors at play beyond taking or not taking a pill, or using or not using a condom.
A range of contextual and internal factors affect a young woman’s decisions about her sexual behavior and HIV risk
Looking at economic empowerment in Tanzania
With this in mind, we journeyed first to Tanzania to meet a group of adolescent girls and young women (aged 15-24) in Shinyanga and Mbeya regions, in the country’s south. They were participating in a cash transfer program called Sauti Project, run by DREAMS, an HIV prevention organization focusing on adolescent girls and young women and funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The 18-month-long program provides participants with cash payments to promote their economic security, independence, and personal empowerment, in the hope that this would reduce their reliance on relationships with older men as a source of money, and therefore lower their exposure to HIV risk.
But because cash transfer programs are short-term, there are concerns that once they end, adolescent girls and young women may revert to risky relationships with men. We wanted to see whether there was a way to design a cash transfer project that would lead to long-term economic empowerment and therefore reduce rates of transactional and intergenerational sex.
Our first task was to understand the sexual and financial decision-making processes of the adolescent girls and young women, as well as their goals for the future. This research had to be handled carefully, as some program participants were understandably wary about sharing stories of their relationships with a group of outside researchers, even after giving informed consent. To make it more comfortable to explore these sensitive topics, we used our scenario-based decision-making game, EthnoLab™, which enabled the 80 participants to reveal their relationship priorities and mindsets indirectly. Follow-up discussions after each game gave participants who wished the chance to discuss their responses in more detail.
The results shed light upon these young women’s vision of what they wanted for their future. We found there were three components: a positive social image, respect and power, and comfort and security. Many adolescent girls and young women desired to be admired in their community. They also valued respect, both from the community and from their partners in relationships. Finally, they sought emotional, social, and economic security. These three components underpinned the decisions and choices girls and young women made about their sexual, relationship, and financial lives. It was often easiest for them to meet these needs through a relationship with an older, more financially powerful, man – even though such a relationship might expose them to HIV.
To explore alternatives, we also conducted EthnoLab™ research with 40 financially empowered women in the community who had successfully established a reliable income while remaining HIV negative. It became clear that one factor that enabled them to meet these goals with a lower exposure to HIV risk was self-agency – the confidence, ability, and support to act for themselves to improve their economic well-being. Building self-agency requires setting attainable goals for making a consistent income, developing business skills, and learning from past mistakes.
EthnoLab Scenario Example
Edina is participating in a workshop as part of a cash transfer program. The teacher informs her that the upcoming payment will be the last. She had grown accustomed to receiving this amount for her new business. Here are some ways that she might react.
She thinks it is best to pursue an additional boyfriend to substitute the cash transfer to meet her needs.
She thinks it is best to continue to stay connected with her peer group from the cash transfer program and build her soap business.
She thinks that she will now have to worry about new issues at home since her partner was not in favor of the cash transfer program.
Self-agency is a crucial component to achieve economic self-sufficiency with low sexual risk-taking
Cash alone won’t cut it
Our findings suggested that the cash transfer project provided resources to make young women more economically and socially independent. But without building their self-agency, the positive impact would not last. So, we designed a framework to help cash transfer programs develop participants’ self-agency through three pillars: emotional, social, and economic efficacy.
3x3 Sustainable Empowerment Framework
Combining the programmatic pillars and phases of progress in a matrix enables a comprehensive perspective of the milestones an adolescent girl or young woman should achieve on her path of empowerment development.
The 3x3 Empowerment Framework, with its 9 programmatic milestones, serves as a high-level reference check for evaluating existing programs and for informing the development of future programs. By zooming in on each milestone, we can identify some of the micro program goals and behaviours that exemplify achievement of that milestone.
Emotional efficacy reframes how young women view risks and rewards, and highlights the gains of long-term self-reliance. Social efficacy focuses on a young woman’s ability to identify and avoid negative relationships and build positive ones. And economic efficacy helps her establish a consistent income and financial independence through education and skills training. The hope is that with greater self-agency, adolescent girls and young women will be more motivated to achieve their goals without engaging in sexual relationships that might put them at high risk of HIV.
“It is good because I earn my own money, I can buy anything I need. Because when you depend on men, sometimes they disrespect you.”
– Young woman, Sauti Project
South Africa: The same, but different
Our next experience of the lives of adolescent girls and young women at high risk of HIV was in Mpumalanga and Kwazulu-Natal provinces of South Africa. Many of the structural issues we’d encountered in Tanzania were present here, too, but the young women we met were not part of any particular program, so their experiences were not filtered through an HIV prevention intervention. While still focusing on HIV prevention, we therefore wanted to apply a more holistic approach to understand adolescent girls’ and young women’s behaviors and the social barriers to HIV prevention. We revised our toolkit to embrace both qualitative and quantitative research.
From our interviews with the young women, we learned that we needed to adjust our framing narrative, since they were not much concerned with HIV prevention and were far more strongly motivated by managing their romantic relationships. Their behaviors were guided by the desire for a healthy emotional relationship, which involved developing skills to navigate and preserve the relationship, and experiencing control and trust. We realized that these adolescent girls and young women were only likely to find an HIV prevention program relevant to them if it was aligned with these goals.
For young women in South Africa, managing a healthy romantic relationship was more urgent than HIV prevention
On the path to a healthy relationship
Our interviews and EthnoLab™ enabled us to map a five-step journey that a young woman takes toward healthy relationships. First, she forms an opinion based on her observations of others’ behaviors and how these relate to her relationship goals. Next, she revises this opinion based on a “reality check” experience in her own relationships. In the third step, she forms new ways to deal with her partner, but these are still driven by her partner’s goals. In the fourth step, she reorients her goals to be driven by her internal motivations. In this stage, she starts to form new, healthy habits, including making new and relatively safer choices to align her lifestyle and relationships with her goals. And finally, she manages to consistently make decisions that match her goals, and to adapt them as her life evolves. This article describes our findings in detail.
This article published in South African Health Review 2019 shares our learnings in more detail:
Understanding HIV prevention behaviors in high-risk adolescent girls and young women in two South Africa provinces
In the next research phase, we applied quantitative analysis to the responses of adolescent girls and young women, which led us to identify three distinct groups or segments. The young women within each segment had similar motivations in terms of what they wanted to get out of their relationships with men. One segment saw a relationship as a lifestyle choice, in another they were primarily seeking affection, desirability and safety, while the third wanted to find respect and equality.
Even with a sense of self-agency, young women have differing motivations for entering relationships
This webinar presents our segmentation findings in more detail
By understanding these differing motivations, we were able to design a new and holistic approach to HIV prevention – one that aligned prevention with their desire for a healthy relationship, and that provided messages and strategies tailored to members of each segment at each of the five steps on their relationship journeys.
“Who knew that HIV prevention research could be explored from a lens that does not present us as hopeless victims, but rather a holistic approach which explores these young women from the psychographic-emotional-behavioral perspective!”
– EthnoLab™ research moderator
We took our learnings back to our local partners in South Africa, and the adolescents and young women themselves, to get feedback and refine our insights. Working with our implementing partners, we hope to pilot new approaches, such as a “relationship bootcamp” in South Africa, to help participants incorporate preventive behaviors and choices into their relationship journeys.
Lessons learned for a work in progress
Our research in the field and interviews with hundreds of adolescent girls and young women have helped us understand what can make an HIV prevention program more effective with this population. First off, nuance matters. While situations, decisions, and risk factors may seem similar, it is vital to understand the individual, her context, and her motivations. Failing to capture the complexity of her situation can compromise the details that could make all the difference to an effective intervention.
Second, the approach should not focus only on one behavior or one prevention product, because that misses the big picture and the structural and psychological factors that shape young women’s decision-making. Once the broader canvas has been sketched in, we can focus on our narrower objectives with a better chance of success. Third, having a journey framework like the one we developed in South Africa helps us systematize our response and map out the possible consequences of different interventions for different segments of the population we’re trying to reach.
As with many complex issues, this story is still a work in progress. We hope our insights are contributing to the efforts to reduce HIV risk among a particularly vulnerable population group. And the feedback from many stakeholders, especially from adolescent girls and young women themselves and the people close to them, gives us some confidence that we’re moving in the right direction.