“IDENTIFYING SPOTS WHERE THE YOUTH IN SWAZILAND MEET THEIR SEXUAL PARTNERS”
Swaziland, the last absolute monarchy in the world has a population of approximately 1.1 million with 59% under the age of 25. Swaziland has the highest prevalence of HIV in the world. More than a quarter of adults and an estimated 40% of pregnant women are infected with HIV. These two statistics indicate that the Swazi youth and women are the populations mostly affected by the HIV/AIDS pandemic in the country.
The Government of the Kingdom of Swaziland (GKOS) is on an aggressive timeline to achieve the PEPFAR 3.0 goals of 90% of people with HIV diagnosed, 90% of those diagnosed on ART and 90% on ART virally suppressed by 2017 with the support of PEPFAR. Epidemiological modelling suggests that the needs of vulnerable populations must be met to achieve the goal of zero new infection. Thus birthing the introduction and implementation of the Priorities for Local AIDS Controlled Efforts (PLACE) study for Swaziland.
The PLACE Study looks to analyze the current HIV risk behaviors and sexual networks among adolescent girls and young women (AGYW) and their partners in 19 Tinkhundla in Swaziland. The study will identify where people are most at risk to acquire HIV infection by pin-pointing popular places where people meet, who they associate with and ultimately find their sexual partners. The targeted population in this study is defined through the Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe initiative (DREAMS) which includes Adolescent Girls and Young Women aged 15 – 25. However, the study found the need to look at the potential male partners of AGYW, thus including young men aged 20-34.
This activity is in support of the DREAMS initiative which is a partnership between USAID, The Gates Foundation and Girl Effect to “reduce HIV infections among adolescent girls and young women in 10 sub-Saharan African countries” including Swaziland. Before the study began, IHM Southern Africa staff were trained on the PLACE Methods and tools, thereafter a protocol for the study was developed, and shared with the HIV Prevention Technical Working Groups for endorsement. In order to gain the study’s approval, the protocol was reviewed by the Science and Ethics Committee in Swaziland as well as the University of North Carolina for international approval.
PLACE Study Implementation
Executing the PLACE study requires a great deal of community mobilization; working with people in the zones or areas which are to be studied, and these people act as community informants. These informants assist in identifying which places the team can visit, and are knowledgeable about where community members meet to socialize, gather, etc. The relationship with community mobilizers is key in implementing Form A of the study which entails the “Spot and Event Identification”. The community mobilizers vary in the roles they play, they consist of taxi drivers, the Indvuna of the areas, community police or zone leaders among others. The PLACE study has currently implemented FORM A in all the 19 Tinkhundla, and through that process the team has been able to identify 114 communities/zones in the 19 Tinkhundla. Thus making the number of spots identified within all the Tinkhundla totaling to just over 1,000 spots.
FORM B of the Study looks at “Spot Verification”, a list of spots mentioned by the community informers, which data collectors use verify as to whether this places exist, and are in operation. The study in this stage also looks at the types of spots identified, which can include: bars, nightclubs, sports events, Shisanyama, restaurants, drinking spots/shebeen, kiosk or stores, and even churches. The study tries to be as comprehensive as possible in categorizing the various spots. The team of data collectors have also completed this phase of the study.
The last phase of data collection for the PLACE Study is FORM C “Patron and Worker Interviews”, where the patrons and workers of the spots are interviewed. Currently, two Tinkhundla have been done for FORM C with a total of 20 spots. In this stage, a sample of the spots will be conducted. Each of the 19 Tinkhundla will be represented in the sampling of the spots. The sample will be based on the volumes of people that visit the spots. So for instance, if a spot has less than 10 patrons at its busiest hour, that spot will be excluded from the sample. Timing for visiting the spots in this stage is crucial, the data collectors need to target the spots at the hours where there are large numbers of patrons.
Another criterion used for the sample is whether or not AGYW visit that spot, and if that spot has GPS coordinates because at a later stage the spots must be able to be mapped. The study is looking to conduct 10 interviews at each spot, divided into male and female interviewees falling in the age groups which are the focus for the study. Provision has been made to interview men falling above the 20-34 age group, as the study notes that they also play the role of being partners to AGYW, however they are not the core focus of the study. The target of interviews to be conducted for FORM C in total is 102 per Inkundla, bringing it to a total of 1900 interviews in all the Tinkhundla.
Outputs Expected from the PLACE Study
A Study report will be produced as well as Inkundla specific fact sheets, as well as maps produced outlining where these spots are, and this information will be disseminated widely. The findings from the PLACE Study will be provided to the HIV Prevention Program in Swaziland in an effort to target HIV Prevention services and concentrate their interventions at the hot spots which will be identified by the PLACE study. These results are also key to the project donor USAID-PEPFAR for their overarching support to the HIV Prevention efforts in Swaziland. The report and fact sheets will also be delivered to the Inkundla included in this study, to inform them of what is taking place in their own communities in terms of where people are most at risk to acquire HIV infections.
Countries Which Have Implemented the PLACE Study
Countries which have implemented the same study are Burkina Faso, Burundi, Guyana, Jamaica, Kazakhstan, Kyrgyzstan, Mexico, Russia, South Africa, Uganda, Uzbekistan, Zambia, and Zimbabwe.
Challenges Faced in Implementing the PLACE Study
Issues around community mobilization have delayed the study, which has been the biggest challenge at this stage. This activity should have been done prior to implementation. Engaging the community at an earlier stage would have allowed for faster data collection, and made the process simpler, with a shorter turn-around time for data collection. The study commenced with the objective of mobilizing 19 Tinkhundla without the knowledge of the actual number of communities and zones in those Tinkhundla. That has been a lesson learnt from the study.
Other challenges include resistance from patrons in conducting the interview, as well as security issues regarding some the spots to be visited. On two occasions, data collectors have been chased away from spot owners and even the patrons themselves when trying to conduct interviews. The instruction to the data collectors is to always withdraw, and discontinue the interview in any threatening situations.
The PLACE study will play a pivotal role in the efforts being made by Swaziland to reach the 90 90 90 targets set, as well as reduce the HIV infection rate. IHM Southern Africa is honoured to be playing an integral role in this endeavor.
Acknowledgements: Mr. Bheki Mamba, IHM Southern Africa Resident Technical Advisor and PLACE Project Lead.