Impact Assessment: Khomanani Campaign (2007-2009) by Jacana Media

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Merafong KCPs in Gauteng during the TB Campaign

An initiative by the Department of Health, Private Bag X828, Pretoria 0001, South Africa Tel: (+27 12) 312 0121/22; www.aidsinfo.co.za Report produced by: Health and Development Africa Pty (Ltd) 1st Floor, No. 1 Milner Place (Building B), Sunnyside Ridge Park 32 Princess of Wales Terrace, Parktown 2193 Tel: (+ 27 11) 484 8217; Fax: (+ 27 11) 484 8238

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Impact Assessment Khomanani Campaign 2007 – 2009

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Participants in TB Day, Matlosana, North West, 2009

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Contents List of Figures..................................................... 4

4 Prevention Campaign .................................... 32

List of Tables ...................................................... 5

Components of the Prevention Campaign ........ 32

Acronyms .......................................................... 5

Reach of the Prevention Campaign ................. 32

Executive Summary ............................................. 6

Impact of the Prevention Campaign on Maintaining Existing Positive Behaviours among Youth ................................................ 33

1 Background and Approach............................. 10 About the Khomanani Campaign .................... 10 Purpose and Methods of the Evaluation Survey ......................................................... 11 Methods of Analysis ...................................... 13 Limitations of the Study ................................ 13 2 The HIV and AIDS Communication Environment in South Africa .......................... 14

Impact of Khomanani on HCT among Youth .... 35 Summary ..................................................... 38 5 Treatment, Care and Support Campaign .......... 39 Components of the TCS Campaign ................. 39 Reach of the TCS Campaign .......................... 39 Impact of the TCS Campaign ......................... 40

Levels of Sexual Risk Behaviour ..................... 15

Summary ..................................................... 41

Levels of Stigma and Openness ..................... 21

6 Tuberculosis Campaign ................................. 42

Access to Media and Information about HIV and AIDS ..................................... 23

Impact of the Hola 6 Campaign ..................... 42

Changes in the Communication Environment ................................................ 24 Discussion ................................................... 25 3 Khomanani Campaign Brand ......................... 26 Exposure to Khomanani Campaign elements ... 26 Brand Recognition ........................................ 28 Zithande ...................................................... 29 Khomanani and Zithande .............................. 29 Where did People hear about Khomanani and Zithande? .............................................. 30

Summary ..................................................... 43 7 Nutrition and Health Promotion Campaigns..... 44 Nutrition Campaign ...................................... 44 Health Promotion Campaign .......................... 45 Summary ..................................................... 56 8 General Conclusions ..................................... 47 9 Annexures ................................................... 49 Annexure 1 .................................................. 49 Annexure 2 .................................................. 50

Summary ..................................................... 31

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List of Figures Figure 1: Percentage of men and women married or living with a sexual partner by age and sex............................14

Figure 13: Impact of Khomanani on knowledge of condoms as an HIV-prevention method ...........................34

Figure 2: Percentage of men and women who had more than one sexual partner in the past year .........................................15

Figure 14: Impact of Khomanani on condom use at last sex to prevent HIV among the general population and young people .........................................35

Figure 3: Percentage of men and women who were involved in MCP ......................16 Figure 4: Percentage of sexually active men and women who used a condom at last sex by age .......................................17 Figure 5: Percentage of people mentioning the benefits men get from being circumcised ..........................................18 Figure 6: Percentage of young men and women who have ever had sex by age .......19 Figure 7: Percentage of men and women drinking heavily by frequency ..................20 Figure 8: Percentage of national sample who have personally been affected by AIDS by age ..........................................24 Figure 9: Percentage exposure to various aspects of Khomanani by age ..................27 Figure 10: Reach of Khomanani by province ................................................28 Figure 11: Estimated numbers of people exposed to various aspects of Khomanani...28 Figure 12: Impact of Khomanani on knowledge of abstinence as an HIV-prevention method ...........................33

Figure 15: Impact of Khomanani on discussing HCT and actual testing with sexual partner among young people .........36 Figure 16: Predictors of discussing HIV testing with a partner .......................37 Figure 17: Impact of Khomanani on HIV testing in the past 12 months among young people ..............................38 Figure 18: Impact of Khomanani on treatment literacy indicators ...................40 Figure 19: Percentage of people who have personally helped care for any orphans whose parents died of AIDS ........41 Figure 20: Percentage of respondents correctly answering various questions about TB ...............................................42 Figure 21: Predictors of knowledge that TB treatment is for 6 months ...........43 Figure 22: Percentage of women who know that HIV can be transmitted through breast milk ................................44 Figure 23: Predictors of knowing that HIV can be transmitted though breast milk ............................................45

Provincial Candlelight Event in Tweespruit, Thaba Nchu, Free State

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List of Tables

Acronyms

Table 1: Percentage of respondents agreeing with various statements concerning alcohol use and HIV and AIDS .............................. 21

ABC

Abstain, Be faithful, Condomise

ACP

AIDS Communication Programme

AIDS

Acquired Immune Deficiency Syndrome

Table 2: Percentage of respondents agreeing with various statements concerning social capital around HIV and AIDS by province ... 22

ARV

Anti-Retroviral Medicines

ART

Anti-Retroviral Therapy

ATL

Above The Line (purchased media)

Table 3: Percentage of respondents agreeing with various statements concerning stigma around HIV and AIDS by province .............. 22

BTL

Below The Line (unsolicited media coverage)

Table 4: Media access: How often do you use radio, different TV channels, magazines, newspapers and internet? ......................... 23

CMT

Community Media Trust

DoH

Department of Health

DRA

Development Research Africa

Table 5: Comparison between the 2006 and 2009 NCS findings .................................. 25

HCT

HIV Counselling and Testing

HDA

Health and Development Africa

Table 6: Percentage exposure to various aspects of Khomanani by settlement type ... 27

HIV

Human Immunodeficiency Virus

Table 7: Percentage of the population who had heard of Zithande who know the main message that the Zithande Campaign is portraying................................................ 29 Table 8: Distribution of sources of Khomanani Campaign information and Zithande Campaign information................. 30 Table 9: Number and percentages of sexually active young men and women having tested for HIV................................ 36 Table 10: Percentage of people knowing that formula feeding and exclusive breastfeeding can prevent MTCT ............... 45

CCMTSP Comprehensive Care Management Treatment Support Programme

JHHESA Johns Hopkins Health and Education in South Africa JHU-CCP Johns Hopkins University, Bloomberg School of Public Health, Center for Communication Programs KCC

Khomanani Communication Consortium

KCP

Khomanani Community Action Partnerships

LSM

Living standards measure

MCP

Multiple and Concurrent Partnership

NCS

National HIV and AIDS Communication Survey

NSP

National Strategic Plan

OVCs

Orphans and Vulnerable Children

PLWHAs People Living With HIV and AIDS PMTCT

Prevention of Mother-to-Child Transmission

PPS

Probability Proportional to Size

PSU

Primary Sampling Unit

Table 12: Household wealth index by race group ...................................................... 50

RRRC

Red Ribbon Resource Centre

SABC

South African Broadcasting Corporation

Table 13: Education levels by age group ....... 51

SADC

Southern African Development Community

STI

Sexually Transmitted Infections

Tuberculosis

TCS

Treatment, Care and Support

UNAIDS

Joint United Nations Programme on HIV/ AIDS

Table 11: Percentage of people drinking heavily in the past month.......................... 46

Table 14: Percentage of men and women employed, unemployed and students ......... 51

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Executive Summary Background The Khomanani Campaign is the main HIV and AIDS focused communication campaign of the South African Department of Health. Khomanani III ran from 2007 to 2009 and aimed to consolidate and build on the success of Khomanani II. It had five major focus areas: • Accelerated Prevention

• Nutrition

• Treatment, Care, and Support (TCS)

• Health Promotion

• TB and HIV All of these focus areas were addressed through sub-campaigns of the Zithande Campaign which underpinned every Khomanani Pillar. The Zithande Campaign encouraged South Africans to adopt a positive, responsible attitude towards HIV and AIDS. It also encouraged respect for others and a willingness to stand together to address the impact of HIV and AIDS on individuals, families and communities. Khomanani III was evaluated in 2009, and this report summarises the findings of this study. The Khomanani evaluation was part of a larger study that was conducted to understand whether HIV communication programmes directed through various media channels are having an impact on knowledge and behaviour relating to HIV in South Africa. The Second National HIV and AIDS Communication Survey 2009 was a collaborative project undertaken jointly by Community Media Trust (CMT), Johns Hopkins Health and Education in South Africa (JHHESA), the Khomanani Campaign (Department of Health) and Soul City, and was managed by Health and Development Africa (HDA). The purpose of this report is to contribute to evidence-based response to the HIV and AIDS epidemic in South Africa and to assist campaign managers and the Department of Health to better understand where and why the Khomanani Campaign has been effective, in order to refine communication approaches going forward.

Methods A national quantitative survey was conducted between June and August 2009. The survey included approximately 10 000 respondents across all nine provinces of South Africa and was designed to be representative of 16–55 year olds across all race groups. The questionnaire

covered socio-demographic characteristics, exposure to various AIDS communication programmes and HIV and AIDS knowledge, attitude and behaviour indicators.

The HIV and AIDS Communication Environment in South Africa Levels of sexual risk behaviour Key drivers of the epidemic, multiple sexual partners and condom use in the context of low levels of male circumcision, were explored. Multiple sexual partners, while not the norm, were fairly common in younger men. Multiple and concurrent partnerships (MCP) were reported less frequently than multiple partners but were also more common among younger men. Men tended to describe their sexual relationships in more causal terms than the women did. Condom use also differed by gender, with fewer women reporting having used a condom at last sex. More youth had used a condom than older people. Some 42% of men in South Africa reported being circumcised, most before 18 years. Knowledge around male circumcision’s role in HIV prevention in general was limited. There also appeared to be some confusion around condom use among circumcised men. Age of sexual debut does not appear to have changed since 2006. Of concern, however,

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is the fact that 5% of young women (16–24 years), who are particularly vulnerable to HIV infection, reported having sex before 15 years. Over a third of young women reported engaging in sexual relationships with men five or more years older than themselves. Wealth inequalities place women at an increased risk of engaging in transactional sex. These relationships are often initiated in places where alcohol is served. Alcohol use was higher in men, with more men drinking heavily and more frequently than women. A large number of both men and women agreed that alcohol lessened one’s likelihood of caring about getting HIV. Over 60% of respondents believed that it was easier to have sex with people who go to shebeens, and of those who did frequent places where alcohol was served, 7% reported having sex with someone they met there for the first time. Alcohol use was also associated with violence.

Levels of stigma and openness Other contributing factors that need to be considered are social capital and levels of stigma towards people living with HIV and AIDS. Levels of social capital and stigma differed between certain sub-populations.

Access to media and information about HIV and AIDS This survey looked at access to various media channels through which AIDS communication programmes (ACPs) are delivered. The most frequently accessed media channels were radio and SABC 1. It is important to consider languages in the delivery of ACP. While isiZulu was the most common language spoken at home, 77% of people in South Africa reported being able to understand English. Personal exposure to HIV and AIDS is also likely to determine the impact that ACPs have on people. People over 50 years were more likely to have cared for someone sick with AIDS. Levels of knowing someone who is HIV positive were generally high and reflect the mature HIV epidemic in the country.

Khomanani Campaign Brand Reach of the campaign differed by province. Over 60% of respondents in the Free State, Gauteng, KwaZulu-Natal, North West and the Eastern Cape had been exposed to Khomanani. Khomanani was more effective in reaching 16–24 year olds, and those in urban formal

and informal settlements. Some 35% of people aged 16–55 years had been exposed to both Khomanani and Zithande. Some 65% of respondents had heard of Khomanani and almost 80% recognised the Khomanani logo. Around 29% of the national population associated the Zithande slogan with mitigating the impact of HIV and AIDS. Some 22% and 19% of the national population were able to complete the Zithande slogans, “Love yourself because you are worth it. Zithande” and “The only thing that spreads faster than HIV is a positive attitude. Zithande” respectively. Overall, television was the most common source of exposure to Khomanani (57%) and Zithande (74%). For Khomanani, the next most common campaign information source was clinics and hospitals (28%) followed by radio (17%). Some 45% of people named radio as an information source for Zithande, followed by clinics and hospitals (10%).

HIV Prevention Prevention messages specifically focused on youth. Some 66% of youth aged 16–24 years had been exposed to Khomanani, while 29% could complete the slogan ‘Take Your Relationship to the Next Level’. Only 3% reported that they, or somebody in their household, had been visited by a Khomanani Community Partner (KCP) at home. There was no significant difference in attitudes towards delaying sexual debut among young people exposed and not exposed to Khomanani. Exposure had an effect on knowledge of abstinence as a means of HIV prevention, with 55% of those exposed to Khomanani compared with 38% of those unexposed, mentioning abstinence. Over 80% of exposed young people and 77% of unexposed young people knew that condoms were a method of HIV prevention. Exposure to Khomanani was associated with 30% times higher likelihood of naming condoms as an HIV prevention method. An association between exposure to Khomanani and condom use at last sex was present with 53% of all people exposed to both Khomanani and KCPs using condoms at last sex, when compared with 35% of those unexposed. That said, exposure to Khomanani did not appear to be a significant predictor of condom use. This may require further analysis.

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Treatment, Care and Support

Nutrition and Health Promotion

HIV counselling and testing (HCT) is a critical bridge between HIV prevention and care and support services. Although the results are not directly comparable, there appears to have been a big increase in the number of people going for HCT since the previous evaluation in 2006. Knowledge of antiretrovirals (ARVs) is vital in order for people testing positive to enrol in care and support programmes. Since 2006, there has been a huge increase in the number of people knowing that ARVs are a treatment for AIDS.

Not all elements of the nutrition and health promotion sub-campaigns were measured in the survey. In terms of nutrition, exposure to Khomanani had an effect on knowledge that HIV can be transmitted though breast milk. This effect was particularly evident in Khomanani’s message target group – women. However, Khomanani had a mixed impact on knowledge of infant feeding options. Women who were exposed to Khomanani and KCPs were more likely to know about formula feeding as a way of preventing MTCT but exposure to Khomanani did not affect knowledge of exclusive breastfeeding.

Exposure to Khomanani had a significant effect on treatment literacy with more people exposed knowing that ARVs are a treatment for HIV and AIDS and that treatment is for life. Exposure to Khomanani was associated with 50% times higher likelihood of knowing there is a treatment for HIV and AIDS and a 40% times higher likelihood of knowing that ARV treatment is for life. When looking at care and support practices, those exposed to Khomanani were less likely to have cared for someone sick with AIDS. This finding requires further investigation. Some 11% of the population had been exposed to both Khomanani and the OVC advert – Caring Together for Children. Exposure to Khomanani, Caring Together for Children and KCPs was associated with an increase in care and support for children affected by AIDS. That said, exposure to Khomanani did not appear to be a significant predictor of having cared for a child whose parents died of AIDS in the last year.

In terms of health promotion, use of alcohol was explored. Exposure to Khomanani did not show any significant impact on the frequency of heavy drinking, visiting places where alcohol was served or having sex with someone who was encountered at a place where alcohol was served.

Conclusions The Khomanani Campaign is an innovative comprehensive HIV and AIDS communication campaign that embraced different themes across a wide variety of media channels. The campaign evaluation used a strong study design. It has generated a large amount of invaluable data on indicators of relevance to understanding the impact, not only of Khomanani, but also of other HIV and AIDS behaviour change communication interventions in South Africa.

Tuberculosis

The following conclusions can be drawn:

Exposure to Khomanani had an effect on knowledge of duration of TB treatment with 83% of exposed people knowing that TB treatment duration is six months. Knowledge of this item has shown a steady increase since the launch of the Hola 6 Campaign. Over half of exposed people knew that TB is more likely in people living with HIV and AIDS (PLWHAs) as compared to unexposed people (49%). However, some 50% of respondents did not know that TB is curable in PLWHAs. Exposure to Khomanani did not have an impact on this knowledge. There is potential room for improvement in messaging around curability of TB in PLWHAs.

• Reach of Khomanani has continued to grow and quite a large number of people recognise the campaign now. However, it is difficult to interpret logo and name recognition since the campaign has been around for seven years. As shown by the number of people who knew that Zithande was about HIV and/ or were able to complete the slogan, fewer people know what a campaign like Zithande means.

• Exposure to Khomanani was associated with some important and significant shifts in knowledge, attitudes and behaviours related to HIV prevention:

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- Knowledge: Exposure to Khomanani was associated with an increase in knowledge of abstinence, condoms and partner reduction as methods for HIV prevention. - Behaviour: Exposure to Khomanani was associated with lower-risk behaviour such as increased condom use at last sex. Khomanani also had a positive effect on young people’s dialogue and testing with their partners.

• Some important HIV prevention messages have not been addressed, and this is shown by lack of impact. This is particularly the case for numbers of sexual partners. This is an important area to consider for future campaigns, but like all communications, the target audience and the creative strategy needs careful consideration. Further analysis of the data from the sexual calendar may be useful in identifying the characteristics of people who have MCP, and this can then be used to inform future campaigns. Another area where Khomanani had no impact was on positive attitudes towards delaying sexual debut. This is an important area to target in the future, especially among youth.

• There is still a gap between people discussing HIV testing and the number of couples actually going for an HIV test together. This may have to do with barriers at an individual, community or health service level. Given the importance of normalising HIV testing in relationships, both HIV prevention and AIDS care, this is a campaign that should be continued.

• Khomanani was also associated with some important changes in treatment, care and support: - Knowledge: Exposure to Khomanani showed significant increases in knowledge of treatment literacy. This is encouraging given government’s goals of putting 1 million people on treatment. Treatment literacy messaging should be continued in order to maintain the levels of knowledge seen in this survey.

- Behaviour: More people exposed to Khomanani cared for a child whose parents died from AIDS than those who were unexposed. Given the difficulties faced by OVCs, community support is vital and these positive findings indicate that Caring Together for Children is starting to be effective.

• However, there were also areas where Khomanani had little impact. There appeared to be a negative association between exposure to Khomanani and support for PLWHAs. This finding is difficult to explain and may require further exploration before adjusting the campaign focus.

• The TB (“Hola 6”) Campaign has consistently been one of the successes of the Khomanani Campaign, and this continues to be the case – with more people knowing about the duration of TB treatment. However, there was no impact on the number of people knowing about curability of TB in PLWHAs. In the future, TB and HIV co-infection may need to be emphasised further as part of this campaign.

• Impact of the Nutrition and Health Promotion Campaigns was mixed. While exposure to Khomanani was positively associated with an increased knowledge about MTCT of HIV through breast milk and of formula feeding as a preventative strategy, there was no association with knowledge of exclusive breastfeeding. Future campaigns will need to focus on exclusive breastfeeding as well as formula feeding as preventative strategies so that women can make informed decisions about infant feeding. This will also contribute towards government’s aim of reducing MTCT to below 5% by 2011. One of the focus areas of the Health Promotion campaign was alcohol use. This was another area where Khomanani did not show any impact. It is critical that future campaigns address social norms around alcohol use.

It is difficult to determine the impact of the Khomanani Community Partnerships (KCP) from this survey as the 36 specific sites where community action was implemented were not specifically sampled. However, of those who reported being exposed to both Khomanani and KCPs, some positive associations were evident. For example, more people exposed to both Khomanani and KCPs reported condom use at last sex to prevent HIV than people who were exposed to Khomanani only. These results suggest that community action may be contributing towards positive HIV prevention and treatment, care and support responses. A detailed evaluation of community action is needed in order to determine the impact of this component of the Khomanani Campaign.

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Background and Approach About the Khomanani Campaign The Khomanani Campaign is a government mass media and communications campaign, which aims to reduce HIV infections and increase care and support for those infected and affected by HIV and AIDS. It is a dynamic campaign that involves extensive use of the mass media, public relations and social mobilisation. It was managed by Khomanani Communication Consortium (KCC) working in collaberation with the Government AIDS Action Plan for the HIV and AIDS, STI and TB Directorate of the National Department of Health. The Khomanani Campaign commenced in August 2001, when the AIDS Communication Team was appointed to implement a two-year HIV and AIDS mass media and communications campaign strategy for the South African National Department of Health (DoH). The initial tender was extended from July 2003 to the end of March 2004. The tender for Khomanani II was awarded to the same team for the period April 2004 to June 2006. This document reports on the evaluation of the third phase of the campaign (April 2007 until June 2009).

The TCS Campaign aimed to reach all South Africans. It specifically promoted the Comprehensive Care Management Treatment Support Programme (CCMTSP) and provided advice on how to support children at risk. TCS communication addressed the treating of opportunistic infections, antiretroviral therapy, psychological care and terminal care. It also promoted positive living. Caring Together for Children, which aimed to increase support for children in need, was a specific component of the TCS campaign.

The Khomanani Campaign aimed to consolidate and build on the success of Khomanani II. It had five major focus areas namely: Accelerated Prevention; Treatment, Care and Support (TCS); TB and HIV; Nutrition; and Health Promotion. All of these focus areas were addressed through sub-campaigns of the Zithande Campaign which underpinned every Khomanani Pillar. The Zithande Campaign encouraged South Africans to adopt a positive, responsible attitude towards HIV and AIDS. It also encouraged respect for others and a willingness to stand together to address the impact of HIV and AIDS on individuals, families and communities.

Findings from Khomanani II and the emergence of drug-resistant strains of tuberculosis (TB) informed the current TB Campaign. This campaign continued with the Hola 6 Campaign and aimed, among other things, at increasing knowledge around TB and HIV co-infection.

The Prevention Campaign aimed to reach all South Africans, but specifically addressed youth and young adults. Some of the most important messages it relayed were about the importance of correct and consistent condom use, delaying involvement in sexual relations for young people and the importance of HIV counselling and testing (HCT). This campaign addressed gender inequalities and gender-based violence, as well as multiple and concurrent partnerships (MCPs) as structural and behavioural drivers of the epidemic. It also aimed to decrease motherto-child transmission (MTCT) of HIV.

The Nutrition Campaign focused on the importance of nutrition as part of the comprehensive package of care for people living with HIV and AIDS. This campaign attempted to reach the general population but was targeted at specific groups, such as people living with HIV and AIDS (PLWHAs), highlighting the importance of basic nutrition. The Health Promotion cut across all of the campaigns. Its conceptual framework encouraged healthy lifestyles, physical activity and health-seeking behaviour. Each of these campaigns had defined target audiences, and key objectives in terms of changes in knowledge, attitudes, social norms and behaviour. These objectives form the basis of the evaluation of the campaign and are presented briefly in subsequent chapters. All of the campaigns utilised the full spectrum of media channels to convey their messages.

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These included the following:

• Above the Line (ATL) or paid advertising • Below the Line (BTL) advertising (this is inclusion of messages in the media through events or providing content)

• The development of print materials • Community level activities Community Action aimed to provide the core campaigns of Khomanani with a face-to-face communication channel. Over the course of the three Khomanani Campaigns, 36 Khomanani Community Action Partnerships (KCPs) have been established nationwide, four in every province. Khomanani has used these partnerships to publicise government programmes at a community level, promote and disseminate small media and reach vulnerable and hard to reach populations with HIV and AIDS messaging. In addition to the media campaigns, KCC continued to use the

existing media distribution centre, called the Red Ribbon Resource Centre (RRRC), where printed material was distributed free of charge on request.

Purpose and Methods of the Evaluation Survey The purpose of the evaluation is to assist campaign managers and the Department of Health to better understand where and why the campaign has been effective, in order to refine communication approaches going forward. A national quantitative survey was conducted between June and August 2009. The survey included approximately 10 000 respondents across all nine provinces of South Africa and was designed to be representative of the 16–55 year-olds across all race groups. For further details on the sample size and methods of the survey, see the box below.

Key features of the evaluation survey • Interviewed 9 728 participants during June to August 2009. • Included persons aged 16–55 years across all provinces and language groups. • A structured questionnaire was designed in a consultative manner with the members of the project team, including external advisors. The questionnaire was translated from English into isiZulu, Afrikaans, isiNdebele, isiSwati, isiXhosa, Sepedi, Sesotho sa borwa, Setswana, Tshivenda and Xitsonga.

• At each selected household, personal at-home interviews were conducted by trained interviewers using a structured, pre-tested questionnaire.

• The questionnaire covered socio-demographic characteristics and various HIV and AIDS knowledge, attitude and behaviour indicators.

• Interviews were conducted in the home language of the respondent. • The interview was approximately 1.5 hours in duration. • A 10% validation check was undertaken in person or telephonically to review the work of each interviewer and ensure validity.

• Data has been weighted up to the national population of South Africa.

More than 9 700 participants were interviewed during June to August 2009.

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The national sample of South Africa was drawn to be representative of the national population. The unweighted data was weighted using the Statistics South Africa 2007 Community Survey as can be seen in Annexure 1. Weighted data has been used throughout the report, while the unweighted data was used for the multivariate analysis to control confounders.

Research team The National HIV and AIDS Communication Survey 2009 (NCS) was a collaborative project undertaken jointly by Community Media Trust (CMT), Johns Hopkins Health and Education in South Africa (JHHESA), Khomanani and Soul City. The survey was managed by Health and Development Africa (HDA). The Johns Hopkins University Bloomberg School of Public Health Center for Communication Programs (JHU-CCP) provided support and technical oversight at all stages of the evaluation. Data was gathered by Development Research Africa (DRA).

Survey design and sampling A multi-stage, stratified sampling approach was used to draw a sample of 400 primary sampling units (PSUs). The PSUs consisted of 2001 Census small areas. All Statistics South Africa’s available and eligible small areas were included in the sample frame. The sample was explicitly stratified by province. Within the provincial strata, the sample was implicitly stratified according to the district councils and area type. There were three stages of sampling:

• Firstly, the PSUs were sampled using probability proportional to size (PPS) principles using a measure of size based on the the number of dwelling units (assumed to

correlate closely with number of households) in a PSU as calculated in the 2001 Census. The measure of size used for the PPS selection was the number of people 16–55 years in the PSU.

• The second and third stages involved a selection of the secondary sampling unit or household, and the selection of one individual from the eligible members of the household, respectively. Based on this sample size of 10 000 individuals, and the utilisation of 400 PSUs or small areas, the proposed sample of small areas at the first stage of selection in the multistage selection process was calculated. The sample was allocated to the explicit strata (provinces) using the square root allocation to ensure that a sufficient sample was obtained from each province to allow for some provincial level analysis. The sample above was calculated based on the population per province aged between 16 and 55 as defined by Statistics South Africa and not the proportion of the entire population residing in each province. After selection of the small areas to be surveyed, the random walk method was used to select the households to be surveyed. No substitution or replacement at a small area level was allowed. An estimated response rate per small area was calculated prior to the commencement of fieldwork to ensure that as close to the required sample size was achieved and that response rates were at acceptable levels. At the third stage, eligible household members aged between 16 and 55 years were randomly selected within a household utilising the KISH grid method. Once the respondent was selected,

Some of the attendees of Candlelight Disability Event in Pretoria, 2009

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the fieldworker pursued only the randomly selected person per household.

Weighting of the sample Due to the sampling design of the survey, some individuals had a greater or lesser probability of selection than others. Sample weights are introduced to correct for bias at the small area, household and individual levels. Sample weights were benchmarked using the 2007 Community Survey provided by Statistics South Africa. These weights reflected the disproportionate allocation of small areas according to the stratification variables – area type and province. This process produced a final sample representative of the population in South Africa for gender, age, race, area type and province.

Questionnaire development The questionnaire for the survey was developed in consultation with JHHESA, JHU-CCP, Khomanani, CMT and Soul City. The structured questionnaire was designed to measure key characteristics of respondents that may influence receptivity to HIV and AIDS communication, exposure to various AIDS campaigns, risk behaviours, and care and support behaviours. Measures included the following:

• Socio-demographic characteristics • Social capital and social norms with respect to HIV and AIDS

• Relation to HIV and AIDS, including personal knowledge of people ill or who have died as a result of AIDS-related illness, community events and activities in relation to AIDS

• Knowledge,

attitudes and perceptions related to HIV prevention, AIDS care and support, TB and prevention of mother-tochild transmission of HIV (PMTCT)

• Ideational factors and social norms related to HIV risk

• The nature and extent of sexual partnerships including duration of partnerships, use of condoms in various relationships and the role of alcohol in relation to sex and HIV

• Prevalence and attitudes towards male circumcision

• HIV counselling and testing (HCT) • Media access and frequency of use

• Overall

exposure to various AIDS communication campaigns in South Africa and specific detailed exposure to specific campaigns including the various components of Khomanani

The information yielded from the survey provides the opportunity for detailed evaluation of the Khomanani Campaign, as well as providing a framework for understanding Khomanani within the broader context of AIDS communication in South Africa.

Methods of Analysis In this survey, people were interviewed and asked about their values and behaviours, regardless of whether or not they had been exposed to Khomanani. The evaluation used quantitative methods, which allow one to determine the impact of Khomanani on the South African population. By comparing the knowledge, attitudes and behaviours of those who had interacted with Khomanani and those who had not, changes attributable to Khomanani could be described. The research team used the statistical package STATA to analyse the data. Both uni-variate and multi-variate analytic methods were used. Regression analysis was used to ensure that any reported changes could be attributed to the intervention and not to other interventions or associated variables that may in fact be the cause of the supposed association.

Limitations of the Study This study has a number of limitations related to the study design. Firstly, it is difficult to draw causal associations using a cross sectional study. Cross-sectional studies are sometimes carried out to investigate associations between risk factors and the outcome of interest. They are limited, however, by the fact that they are carried out at one point in time and give no indication of the sequence of events – whether exposure occurred before, after or during the onset of the desired outcome. Since this study relied on self-reported data, it is prone to bias, which can be introduced by the respondents. Bias can occur when participants under- or over-report on certain questions intentionally and when participants fail to recall the time of the events and the number of events.

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The HIV and AIDS Communication Environment in South Africa This section contains general findings of the survey, including a number of factors that influence HIV risk. It does not look at the Khomanani Campaign per se, which will be examined in further chapters. • Many respondents were not married; among

Some of the key demographic indicators that came out of the survey are further broken down by race and age.

the 16–24 year-olds, 80% were single, 14% were not married and not living with a partner but in a steady relationship, and 2% were not married but living with a sexual partner. Only 31% of the 25–34 year-olds were married and living with a spouse. In the older age groups (50+), 49% were married and living with a spouse. Figure 1 below shows the percentage of people who were married or living with their sexual partner by age group and sex. As depicted in this figure, stable relationships appeared to be uncommon for younger men.

Key findings are the following:

• Some 18% of the sample had attained only primary school level education or less; education levels were inversely related to age, with 46% of those over 50 years having completed primary school education or less.

• Over a quarter (26%) of Black respondents, 14% of Coloured respondents and under 3% of Indian and White respondents had sometimes, or often, gone without enough food to eat.

Figure 1: Percentage of men and women married or living with a sexual partner by age and sex

Females

Males

70 55

60 50

15 3

1 16-19

20-24

25-29

30-34

35-39

40-44

45-49

50-55

Further contextual analysis is currently underway as part of the overarching NCS report and will be made available.

Stable relationships appeared to be uncommon for younger men. 14 KHOM_IMPACT_ASSESS_06-09.indd 14

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Levels of Sexual Risk Behaviour A “Think Tank” meeting on HIV prevalence in southern Africa, convened by SADC and UNAIDS, concluded that “high levels of multiple and concurrent sexual partnerships by men and women with insufficient consistent, correct condom use, combined with low levels of male circumcision are the key drivers of the epidemic in the sub-region”. Contributing drivers identified include male attitudes and behaviours, intergenerational sex, stigma and untreated viral STIs, while social and structural drivers of the epidemic include high population mobility, inequalities of wealth, cultural factors and gender inequality.1 This section describes a number of important sexual risk behaviours.

Multiple sexual partners This survey measured peoples’ knowledge of the risk of having multiple sexual partners. While 86% of people agreed that “having several sexual partners at the same time makes

it more likely that you will get HIV” and half of the respondents agreed that people in their communities are openly talking about the risk of HIV from having sex with more than one partner, the proportion of people having multiple sexual partners was still quite high as shown in Figure 2. Figure 2 shows that significantly more men reported having multiple sexual partners in the past year when compared to women. This was true across all age groups. Men aged 20–24 years were most likely to report having had multiple sexual partners in the past year. While the proportion of people having had multiple sexual partners in the past year decreased with age in both men and women, men still had high levels of multiple sexual partners in the older age groups. While these levels of reported multiple sexual partnerships are certainly sufficient to maintain the spread of HIV within sexual networks, it is encouraging to note that people reporting multiple sexual partners were in the minority. This has important consequences for AIDS communication programmes in the country.

Figure 2: Percentage of men and women who had more than one sexual partner in the past year

Females

33 29

Males

25 19

20 15 10

20-24

25-29

30-34

35-39

40-44

45-49

50-55

0 16-19

1 Experts Think Tank on HIV prevention in high-prevalence countries in Southern Africa. Southern African Development Community (SADC) Meeting Report, May 2006. Gaborone: SADC HIV and AIDS Unit.

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Despite these high levels of multiple sexual partnerships, there appears to have been an encouraging decline in the number of people reporting multiple sexual partners in the past year. In 2006, 16.5% of people reported having multiple sexual partners in the past year, while in 2009 this percentage was 11.4%. This reduction was apparent in both men and women. Some 19% of young men and women (16–24 years) reported having more than one sexual partner in the past 12 months. Reported number of multiple sexual partners among young men was similar across the two communication surveys at 33% in 2006 and 31% in 2009. However, there appears to have been a reduction in the reported number of

multiple sexual partners among young women – from 12% in 2006 to 7% in 2009. The survey also measured the number of people who had more than one sexual partner in the past month. While a more detailed measure of concurrency will be analysed in the future using details from the sexual calendar in the questionnaire, Figure 3 below shows the percentage of respondents reporting more than one sexual partner in the past month. Although these sexual partnerships may not have been overlapping, in terms of risk of HIV transmission, these partnerships may be classified as concurrent, as HIV viral load is highest 4–6 weeks post-infection. This high viral load increases the risk of HIV transmission.

Figure 3: Percentage of men and women who were involved in MCP

Females

Males

12 10 8

6 4 2 0

2 16-19

3 2 20-24

25-29

30-34

0 35-39

1 40-44

4 1

0 45-49

50-55

Some 19% of young men and women (16–24 years) reported having more than one sexual partner in the past 12 months.

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Concurrent partnerships were reported fairly commonly among sexually active young men, with over 10% of men in the age categories 16–19, 20–24 and 25–29 years reporting two or more partners in the past month. Among sexually active women, reports of two or more partners in the past month were much lower, and in any given age group this did not reach higher than 2% of women. Number of partners in the past 12 months was inversely correlated with the age of the respondents. When looking at how people classified their relationships with different sexual partners, more men described their relationships as “friends”, “someone I’ve known for a while”, “someone I’ve just met” or “a one-night encounter”.

Correct and consistent condom use Correct and consistent condom use is an important means of preventing HIV infection, as well as preventing other STIs and unwanted pregnancies. Knowledge of condom use as a method for preventing HIV was very high with 86% of the population knowing that they could be used to prevent HIV infection. Figure 4 below shows the proportion of sexually active respondents who used a condom at last sex by age. Condom use was inversely proportional to age as youth reported much higher rates of condom use than older age groups. More men reported using a condom at last sex than women. We also looked at condom use by relationship status. Condom use was reported less often in people who were married or lived with their partner.

Figure 4: Percentage of sexually active men and women who used a condom at last sex by age

80 70

Females 68

60 49

Males

51 43

43 32

34 28 20

21 11

10 0

16-19

20-24

25-29

30-34

Young girls are at particular risk for HIV, and the findings that fewer young women seem to be using condoms in South Africa is an important area for strategic communication and action in the country.

Low levels of male circumcision Male circumcision has been proven to have a partial protective effect on HIV transmission. Based on existing evidence, male circumcision has been recognised as an additional

35-39

40-44

45-49

50-55

intervention to reduce the risk of heterosexually acquired HIV infection in men.2 However, we have very little information about what people know and assume with regard to circumcision. Circumcision is conducted in many different ways for many different reasons on men of different ages. In addition to this, there are many cultural, religious, social and medical practices associated with circumcision around the world. This makes it harder to properly implement, monitor and evaluate circumcision

2 Gray RH, Kigozi G, Serrwada D, Makumbi F, Watya S, Nalugoda F et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. (2007). Lancet 369(9562):657-66.

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interventions as part of comprehensive HIV prevention services. Given the importance of this intervention, this survey asked people about their attitudes and practices around circumcision, particularly as it relates to perception of HIV risk. There are low levels of male circumcision in South Africa. Nationally, 42% of men aged 16–55 years reported being circumcised. It is important that circumcision occurs before men start having sexual intercourse if the HIV risk

reduction benefits are to accrue.3 Around 25% of men had been circumcised before 18 years, while 17% had been circumcised at later ages. Both men and women were asked what they thought the benefits of male circumcision were. Figure 5 shows that about a third of people knew that male circumcision reduces the risk of contracting diseases in general. However, less than 10% of people mentioned that male circumcision reduces the risk of getting HIV.

Figure 5: Percentage of people mentioning the benefits men get from being circumcised

35 30 25 20 15 10 5 0

14 8

Reduces the risk of other diseases

No benefits

Keeps you clean and healthy

There is room to increase messaging around the benefits of male circumcision in terms of HIV risk reduction. However, messaging around this issue needs to be clear and informative as increased knowledge around male circumcision’s benefits can lead to the mistaken belief that circumcision alone can offer protection against HIV infection. This may mislead circumcised men to stop using condoms. It is critical that circumcised men do not develop a false sense of security and assume that circumcision is fully protective against HIV infection even if they do not use condoms. It is clear that carefully constructed messages around male circumcision are needed.

Age of sexual debut Delaying sexual debut is one of the cornerstones of many HIV-prevention responses because people who abstain from sexual intercourse are less likely to contract HIV. Young people who engage in sexual intercourse at an early age

Reduces the risk of getting HIV

4 Makes sex more pleasurable

may not have the knowledge and information needed to protect themselves. On these grounds, delaying the age at which people start to have sex, together with reducing the numbers of partners that people have, are believed to be critical in reducing the rate of spread of HIV.4 Mean age of sexual debut for young people does not seem to have changed. This survey showed that sexual debut for those between 16–24 years was 16.3 for men and 17.2 for women, while the NCS 2006 showed that mean age for sexual debut among young people was 16.2 for men and 17.1 for women. For 16–24 year-olds, some 70% of young people had ever had sex. Figure 6 below shows the percentage of people aged 16–24 years who have ever had sex. By 16 years of age, some 31% of girls and 17% of boys had had sex, and by 19 years, 76% of girls and 70% of boys had ever had sex.

3 Gray RH, Kigozi G, Serrwada D, Makumbi F, Watya S, Nalugoda F et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. (2007). Lancet 369(9562):657–66. 4 Hallet TB, Gregson S, Lewis JJ, Lopman BA, Garnett GP. Behaviour change in generalized HIV epidemics: impact of reducing cross generational sex and delaying age at sex debut. (2007). Sexually Transmitted Infections.1:150-54

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Figure 6: Percentage of young men and women who have ever had sex by age

Females 100

87 76

86 78

56 57

60 40

Males

31 17

0 16

When looking at the percentage of young people who had had sex below the age of 15 years, in 2006 and 2009, a similar pattern emerged. In 2006, 11% of young men and 3% of young women reported having had sex below the age of 15 years, while in 2009, these figures were 14% and 5% for boys and girls respectively. Young girls are at particular risk for HIV and these findings need to be considered in order to respond to this epidemic driver appropriately.

Intergenerational sex Intergenerational sex is a driver of the HIV epidemic since awareness of HIV risk in these relationships is low.5 In this analysis, intergenerational sex was defined as having at least one sexual partner who was five years

older or younger than the respondent. In looking at young women (16â&#x20AC;&#x201C;24 years), 38% of this group reported engaging in sexual relationships with men five years older or more than them. Given the risk associated with intergenerational sex, this is an important driver that needs to be addressed by HIV prevention campaigns in South Africa.

Inequalities in wealth and transactional sex This survey asked a number of standardised questions about household items. A living standards measure was calculated from these items. Some 28% of the population reported a low standard of living while 29% reported a medium-living standard. Inequalities in

Some of the attendees of STI event in Giyane, Limpopo, 2009 5 Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability.(2008). AIDS. 22(4):17â&#x20AC;&#x201C;25.

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wealth assist in the spread of HIV because poorer people, usually women, are forced into sexual relationships to ensure the survival of themselves and their children. Around 3.5% of relationships included provision of sex in return for money or goods, and 2.6% included giving money or goods in exchange for sex. Closer examination of the data show that these transactional relationships do not appear to be mutually exclusive, for example, relationships which included paying for sex with money or goods, also involved receiving money or goods in exchange for sex. In other words, some people reported giving money in exchange for sex as well as receiving money in exchange for sex â&#x20AC;&#x201C; often in the same relationship. However, some patterns were revealed when looking at transactional sex in different types of sexual relationships. People in stable relationships reported less transactional sex less frequently as compared with people in casual relationships. Transactional sex was more prevalent in onenight encounters. Some 14% of men provided money in exchange for sex in a one-night

encounter, while about a tenth (11%) of women provided sex in exchange for money in these short relationships.

Alcohol Sexual relationships, especially those which are transactional in nature are often initiated in places where alcohol is served. In addition, the consumption of alcohol is often considered to influence decision-making, and its consumption has been shown to be associated with risky sexual behaviour. This has important implications for the spread of HIV and AIDS. We also looked at the number of men and women who drank heavily and how often they did so. Drinking heavily was defined as having five or more drinks in one sitting for men and four or more drinks on one occasion for women. Of those who did drink alcohol, many men (and women) drank heavily often, with 26% of all men drinking heavily a few times a month and 19% of men drinking heavily almost every week. Some 3% of men reported drinking alcohol heavily almost every day (Figure 7).

Figure 7: Percentage of men and women drinking heavily by frequency

Females

Males

25 19

20 12 10

5 0

1 A few times a month

Almost every week

Almost every day

Sexual relationships, especially those which are transactional in nature, are often initiated in places where alcohol is served.

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The frequency of these drinking sessions is of concern, since it appears that alcohol leads to decreased HIV risk perception. When asked whether they agreed with the statement – “If you and your sex partner have too much to drink, neither one of you will care about getting HIV” – around 50% of both men and women agreed with this statement (Table 1).

Approximately 31% of men in the national population reported visiting a shebeen, bar, tavern and/or nightclub where alcohol was served in the past month, while only 7% of women reported this. Table 1 shows that significantly more men (68%), compared to women (57%) felt that it is easier to have sex with people who go to clubs/shebeens (p=0.00).

Table 1: Percentage of respondents agreeing with various statements concerning alcohol use and HIV and AIDS Percentage agreeing with statement

Females

Males

Total

P-value

If you and your sex partner have too much to drink, neither one of you will care about getting HIV

50.1

51.3

50.6

0.52

It’s a lot easier to have sex with people who go to clubs/shebeens

56.8

68.0

62.1

0.00

Some 7% of people said that the last time that they went to a shebeen, bar, tavern and/or nightclub they had sex with someone who they met there for the first time. Alcohol was also associated with violence. For both men and women, those who drank heavily often were more likely to be involved in violence. Men who drank heavily often were more likely to be the perpetrators of violence, while women who drank heavily often were more likely to report having been beaten up in the past year. In general, more men reported having been involved in physical violence in the past year when compared with women. Twice the proportion of men (16%) reported being involved in a fight in the last 12 months compared to women (8%). More men (15%) reported having beaten up someone else than those who reported being beaten up by someone else (11%).

Levels of Stigma and Openness In order to understand the environment in which AIDS communication programmes are operating, it is necessary to look at level of social capital and stigma.

Social capital In order for those who are infected and/or affected with HIV to receive help and support, positive social relations in the family and wider community, otherwise known as social capital, are important. People were asked whether they agreed or disagreed with a number of statements to determine their views on social capital. These statements included the following:

• whether they thought that leaders in their communities took HIV and AIDS seriously

• whether they thought that people in their communities were joining together to help people with HIV and AIDS

• whether they trusted the people within their communities Respondents in KwaZulu-Natal showed the least agreement with all three of the statements, compared with respondents from the other provinces. Mpumalanga showed the most promising results, followed closely by the Free State and the Northern Cape (Table 2).

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Table 2: Percentage of respondents agreeing with various statements concerning social capital around HIV and AIDS by province Leaders in their communities take HIV and AIDS seriously

People in their communities are joining together to help people with HIV and AIDS

Trust most people in their communities

Western Cape

46.7

48.0

52.0

Free State

48.8

43.1

63.4

Gauteng

47.3

44.2

49.6

KwaZulu-Natal

35.8

30.7

47.5

Limpopo

47.4

45.9

57.7

Mpumalanga

46.6

53.2

61.1

North West

44.9

46.5

53.3

Northern Cape

50.5

49.0

54.7

Eastern Cape

45.3

37.3

59.3

Total

44.6

42.1

53.4

Stigma The stigma associated with HIV and AIDS is a matter of great concern. Stigma was measured by means of agreement with a set of statements, for example, â&#x20AC;&#x153;I would be embarrassed to be seen with someone who everyone knows has HIVâ&#x20AC;?. Respondents from the Western Cape tended to agree more with the statements, and in turn showed the greatest stigma towards HIV and AIDS, as seen in Table 3 below. Stigma associated with HIV and AIDS was much lower in Mpumalanga, with most of the respondents disagreeing with the statements. Table 3: Percentage of respondents agreeing with various statements concerning stigma around HIV and AIDS by province People with HIV will soon lose their friends

When you learn that you have HIV, your life is over

I would be embarrassed to be seen with someone who everyone knows has HIV

Western Cape

54.3

28.1

24.7

Free State

39.4

17.7

20.2

Gauteng

47.5

19.5

15.9

KwaZulu-Natal

37.6

16.5

14.2

Limpopo

43.6

25.9

16.7

Mpumalanga

35.9

16.8

8.0

North West

39.8

16.9

17.4

Northern Cape

52.5

24.2

15.6

Eastern Cape

35.0

21.5

17.5

Total

42.7

20.4

16.6

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Stigma associated with HIV and AIDS was exhibited most commonly by members of the white population, older individuals (50–55 years) and those who were employed. In contrast, stigma was less prevalent in the Black population, younger individuals (16–24 years) and among students.

Access to Media and Information about HIV and AIDS The Khomanani Campaign and other HIV and AIDS communication campaigns in South Africa utilise various domains of communication, for example, mass media (broadcast, print and outdoor), small media (posters, booklets, utility items), dialogue-oriented approaches (such as the AIDS Helpline) and social

mobilisation, creating dialogue and action at local and community level. This survey measured the frequency of access to various channels to contextualise the reach and impact of Khomanani Campaign components, and to inform future strategy. Frequency of access to various media channels is shown in Table 4 below. Half of people accessed radio and SABC 1 daily. Some 13% of people never listened to the radio and 18% of people never watched SABC 1. Newspaper readership was relatively high with 68% of the population reading a newspaper once a week or more often. These are similar findings to those of the NCS 2006. Internet and DSTV exposure was still very low, with over 80% of the population never accessing these two media channels.

Table 4: Media access: How often do you use radio, different TV channels, magazines, newspapers and internet? Media access

Never

<once a week

1–3 days/ week

4–6 days/ week

Every day

Listen to radio 12.9

13.5

14.4

11.4

47.8

Watch SABC 1

18.4

12.0

9.5

48.1

Watch SABC 2

24.3

15.6

19.4

10.7

30.1

Watch SABC 3

32.9

16.6

18.7

9.3

22.5

Watch eTV

28.2

11.4

14.5

10.9

35.1

Watch DSTV

80.3

2.9

2.7

2.2

12.0

Read a magazine

43.7

26.5

18.2

5.2

6.3

Read a newspaper

32.5

21.9

19.3

8.6

17.7

Use the internet

81.5

5.3

4.7

1.8

6.7

The Khomanani Campaign and other HIV and AIDS communication campaigns in South Africa utilise various domains of communication.

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There were no real differences across overall media access by age, although media channels did differ. Language is also an important factor to consider when looking at access to media and information about HIV and AIDS. IsiZulu was the language most commonly reported as spoken at home (27%), followed by isiXhosa (16%) and Afrikaans (15%). However, more than three-quarters of people (77%) reported being able to understand English when it was spoken. The next most commonly understood languages were isiZulu (46%) and Afrikaans (30%).

People are affected by HIV and AIDS in many ways, and this may impact on what they see and hear in the media. For example, increasing numbers of people infected and ill with AIDS mean that many respondents’ awareness of HIV and AIDS may be heightened in South Africa through personal contact with those affected. Some 10% of 16–24 year-olds, 18% of 25–49 year-olds and a quarter of those over 50 years have personally helped to care for a person sick with AIDS. Just less than half of people reported personally knowing someone who is HIV positive and knew someone who had died of AIDS (Figure 8).

Figure 8: Percentage of national sample who have personally been affected by AIDS by age 16-24 47

50 40

25-49 47

50+ 46

25 18

20 10

10 0 Know someone who is HIV+

Know someone who has died of AIDS/AIDS-related illness

Changes in the Communication Environment When looking at the communication environment, it is important to understand the changes that have occurred over time. A comparison of some of the key findings from

Personally ever helped take care of someone who is sick with AIDS

2006 and 2009 are found in Table 5. The table shows that there has been an increase in the number of people mentioning faithfulness and partner reduction as ways to prevent HIV. There has also been an increase in the number of people tested for HIV.

There has been an increase in the number of people mentioning faithfulness and partner reduction as ways to prevent HIV.

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Table 5: Comparison between the 2006 and 2009 NCS findings

General

Knowledge of methods to prevent HIV transmission

Behaviour

2006

2009

Mean age (years)

33.3

30.2

Male

49.2

48.7

Ever had sexual relationship

85.2

88.7

Had sexual relationship in past 12 months

82.2

80.3

Condom use

90.7

85.6

Faithfulness

26.0

39.1

Abstinence

40.1

37.4

Partner reduction

6.7

12.2

Used condoms to prevent HIV

44.6

40.2

Used condoms at last sex

43.3

39.8

HCT â&#x20AC;&#x201C; ever tested

47.1

61.4

HCT â&#x20AC;&#x201C; tested in the past 12 months

24.1

36.9

Multiple partners in the last 12 months

16.5

11.4

Multiple partners in the last 12 months: males

25.9

20.1

Multiple partners in the last 12 months: females

7.2

3.0

Multiple concurrent partners: >1 partner in the past month

5.4

4.9

Discussion The levels of condom use at last sex reported in this study are encouraging. The results suggest considerable changes in sexual behaviour among South Africans over time. That said, levels of condom use among older respondents and in longer-term relationships remain fairly low. This is alarming in view of the high rates of young women reporting partnerships with men who are older than themselves. Levels of multiple sexual partners are low overall, but are high in sub-sets of people especially for young men.

While targeted interventions to address this risk behaviour are relatively new and one cannot expect to see behaviour change so soon, there appears to have been an increase in knowledge of the risks posed by multiple sexual partners and a small decrease in the number of partners reported. Further interventions and evaluations of their impact on this important area are needed. The relationship between alcohol and risky sexual behaviour is complex, but results suggest that this is an important area for intervention which cannot be ignored.

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Khomanani Campaign Brand The essence of the Khomanani brand is: Caring together for Life. The brand proposition is: Khomanani enables you to live a better life. The target audience for the Brand Campaign is: All LSM groups and all South Africans. The campaign objectives were to:

• Position the Khomanani brand as a strong, distinctive, government-led initiative against HIV and AIDS. This social brand incorporates a challenge to action.

• Create a unified brand and facilitate recognition, buy-in and support through use of mass media and other relevant communication platforms.

• Target the individual (person) within the local, provincial and national context to ensure personal responsibility and advocacy. While some of the Khomanani sub-Campaigns had some form of individual branding (such as slogans or logos), all of the campaigns also carried the Khomanani Campaign name and logo. While the mass media and communications described earlier formed the backbone of the Khomanani Campaign, key elements of the approach of the campaign included encouraging social-level change, not only individual-level change, and building opportunities for dialogue into the campaign. This implied community level activities, which were realised through the Khomanani Community Action interventions.

Exposure to Khomanani Campaign Elements One series of questions in the survey asked about exposure to a range of HIV and AIDS communication programmes. It must also be pointed out that exposure to communication programmes overlapped considerably, meaning that those who watched one communication programme were also more likely to have watched the others. As described in Section 1, Khomanani had a number of different campaigns. Reach of the various campaigns and of Community Action is shown in Figure 9 on the following page. All of the aspects of Khomanani were more effective in reaching people 16–24 years old, followed by the age group 25–49 years old. Reach was lower in people 50 years and older. This pattern was evident across several campaigns, not just Khomanani; this decline in exposure by age may be related to media access, although the survey found differences in media access channels rather than frequency of media access in older age groups.

While this survey asked respondents whether they, or anyone in their household, had been visited by a KCP, the 36 specific sites where community action was implemented were not specifically sampled. While the campaignspecific sections below show the effect of KCP, the sampling constraints should be borne in mind.

Reach of all aspects of Khomanani was highest in urban formal settlements and followed closely by urban informal settlements.

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Figure 9: Percentage exposure to various aspects of Khomanani by age

16-24

25-49

50+

30 20

10 0

Khomanani Campaign

Hola 6 Campaign

Zithande Campaign

Reach of all aspects of Khomanani was highest in urban formal settlements and followed closely by urban informal settlements. Interestingly, the Hola 6 Campaign reached 48% of people living in tribal settings which is approximately

OVC Campaign

KCP

the same reach as the campaign had in urban settings. Reach in peri-urban and farming settlements was consistently lower than in any of the other settlement types (Table 6).

Table 6: Percentage exposure to various aspects of Khomanani by settlement type Exposure to campaigns

Urban formal

Urban informal

Peri-urban

Tribal setting

Farming

Hola 6 Campaign

52.9

49.5

33.4

48.0

30.4

OVC Campaign

13.4

9.9

4.3

9.1

4.0

KCP

8.6

4.2

4.4

1.4

Khomanani Campaign

64.8

61.0

41.9

62.8

39.8

Zithande Campaign

47.9

47.0

32.8

44.4

27.2

Reach of Khomanani differed significantly across the nine provinces (Figure 10). Khomanani had a reach of over 60% in the Free

State, Gauteng, KwaZulu-Natal, North West and the Eastern Cape and lowest reach in the Western Cape (49%).

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Figure 10: Reach of Khomanani by province

Gauteng 68.9%

Limpopo 55.4%

North West 68.9%

Northern Cape 57.2%

Gauteng

Free State 67.6% Lesotho

Mpumalanga 59.3%

KwaZuluNatal 60.5%

Eastern Cape 67.4% Western Cape 49.3%

Brand Recognition Khomanani When asked specifically about the Khomanani Campaign, 65% of people (18 million people) said that they had heard of the Khomanani Campaign in the last 12 months. This is a significant increase from the 2006 survey where less than half of all respondents had heard of the campaign, although it was suspected to be an underestimate. Almost 80% (21 million

people) recognised the Khomanani logo in the 2009 survey (Figure 11). This is a slight decline from the 2006 evaluation, which found that 90% of the national population recognised the Khomanani logo, and there were very high levels of recognition of the Khomanani brand and awareness of what Khomanani did.

Figure 11: Estimated numbers of people exposed to various aspects of Khomanani

25,000,000 20,000,000

21,000,000 18,000,000

15,000,000

16,000,000 13,000,000

12,000,000

10,000,000 4,000,000

5,000,000

3,000,000

0 Heard of Khomanani

Recognised Recognised Recognised Recognised Heard of RRC Heard of Khomanani Hola Stop TB logo DUMMY logo on radio â&#x20AC;&#x153;Zithandeâ&#x20AC;? Logo 6 logo

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Zithande The Zithande Campaign was a call to all South Africans to take steps to contribute to the reduction of HIV and AIDS, in turn reducing the impact of HIV and AIDS on individuals, families and communities. The concept was that if we all portray a positive, responsible attitude towards HIV and AIDS, we reflect our love for life, our respect for others and show willingness to take a stand to mitigate the impact of HIV and AIDS. Individuals needed to question their self-worth in relation to their health emphasising the concept of “self-worth – uku Zithande”. South Africans were called upon to:

• Show support for people living with and

Some 49% of the national population had heard of or seen the word or concept Zithande, and of these people, 81% of them were able to explain that Zithande means “self-worth” or “I am worth it” or “love oneself”. Some 40% of the national population believed that the main message being portrayed by the Zithande Campaign is ‘Our love for life’, 24% believed it is ‘Our respect for others’ and only 9% believed it is ‘A willingness to take a stand to mitigate the impact of HIV and AIDS’. About a fifth of people believed that it is a combination of the above three messages (Table 7).

affected by HIV and AIDS

• Take personal responsibility in relation to their life, health and HIV and AIDS

• Demonstrate a “nation caring together for life” Table 7: Percentage of the population who had heard of Zithande who know the main message that the Zithande Campaign is portraying Message being portrayed

Percentage of national population

‘Our love for life’

40.3

‘Our respect for others’

24.4

‘A willingness to take a stand to mitigate the impact of HIV and AIDS’

9.3

All of the above

19.8

It is suggested that the figure of 29% is the best indication of the reach of Zithande and the extent to which the meaning is understood, as it includes a message on HIV and AIDS. Respondents’ ability to complete Zithande Campaign slogans provides an even better indication of understanding of the extent to which people understand this campaign, as has been analysed below. Two slogans are used by the Zithande Campaign:

• ‘Love yourself because you are worth it. Zithande’

• ‘The only thing that spreads faster than HIV is a positive attitude. Zithande’ Some 22% of the national population were able to complete the first slogan, and 19% of people were able to complete the second slogan.

Khomanani and Zithande Khomanani and Zithande are difficult communication campaigns to evaluate given the scope and breadth of work and the complexity and number of messages. Reach data in the tables and figures above show exposure to the various programmes using one or two items, for example, having heard of Khomanani or Zithande. However, Khomanani is a ubiquitous brand and a more refined measure of exposure to the Khomanani Campaign as a whole includes a number of different measures of exposure, such as having heard of the Khomanani Campaign, recognising the Khomanani logo and, since the Zithande Campaign was cross-cutting, having heard of Zithande. Reach of the Khomanani Campaign when using this refined measure of exposure is presented in this section.

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Overall, 35% of the national population, or about 9.5 million people, were exposed to Khomanani when using the more refined measure of exposure. Of those exposed, younger people formed the majority of people who had been reached by Khomanani, and exposure was significantly lower among older age groups. This trend was correlated with employment level and education status where students were significantly more exposed (44%) than either employed or unemployed people. More people with tertiary education levels (46%) were exposed than people with lower education levels. When considering exposure to Khomanani by race, settlement type and province, exposure was very low (<14%) among White, Indian and Coloured people; exposure was low (<30%) in KwaZulu-Natal, Limpopo, Northern Cape and Western Cape, and exposure was low (<20%) in peri-urban and farming settlements. Some 7% of the national population had been exposed to a KCP representative in the past 12 months. We used this refined measure of exposure to Khomanani when looking at impact of the Khomanani Campaign – the results of which are presented in the following chapters.

Where did People hear about Khomanani and Zithande? Respondents were asked where they had heard about the Khomanani Campaign and the word or concept “Zithande”. Many people had heard about them from more than one source. Overall, as seen in Table 8 below, the most commonly cited source of exposure to Khomanani and Zithande was television, accounting for 57% and 74% of all sources of information respectively. Clinics and hospitals were the second-most commonly cited source of campaign information (28%). This has increased from 2006 where clinics/hospitals only accounted for 21% of Khomanani Campaign information. Radio as a source of campaign information has decreased substantially since 2006, as is the case for posters, booklets and billboards. Despite this decline, radio was the second greatest source of exposure to Zithande (45%). School, friends, community radio, HIV and AIDS organisations, community events and KCPs together as a source of exposure for both the Khomanani Campaign and Zithande accounted for less than 10%.

Table 8: Distribution of sources of Khomanani Campaign information and Zithande Campaign information* Message being portrayed

Khomanani Campaign

Zithande Campaign

57%

74%

Clinic/hospital

28%

10%

Radio

17%

45%

Posters

14%

Booklets

12%

Billboards

12%

*Restricted to those who had heard of Khomanani/Zithande

More people with tertiary education levels (46%) were exposed than people with lower education levels.

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Summary • Reach: Over 60% of respondents in the Free State, Gauteng, KwaZulu-Natal, North West and Eastern Cape had been exposed to Khomanani, whereas in the Western Cape only 49% were reached. Khomanani was more effective in reaching 16–24 yearolds, and those in urban formal settlements and urban informal settlements. Using the refined measure of exposure, which included exposure to both Khomanani and Zithande, some 35% of people aged 16–55 years had been exposed to Khomanani.

• Branding and messaging: Some 65% of respondents had heard of Khomanani and almost 80% recognised the Khomanani logo. Around 29% of the national population associated the Zithande slogan with mitigating the impact of HIV and AIDS. Some 22% and 19% of the national population were able to complete the first and second Zithande slogans respectively.

TV followed by radio, and clinics and hospitals emerged as the main source of information around Zithande and Khomanani, when compared with posters, booklets and billboards.

• Sources of information: TV followed by radio, and clinics and hospitals emerged as the main source of information around Zithande and Khomanani, when compared with posters, booklets and billboards.

Health Promotion billboard

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Prevention Campaign The main goals of the Prevention Campaign were to:

• Intensify and strengthen the ABC strategy, especially among young people, including delaying the onset of sexual debut, primary and secondary abstinence, correct and consistent condom use and reducing the number of sexual partners.

• Increase the sense of personal risk of HIV infection, and increase the attitude of greater responsibility for sexual behaviour. This was primarily through increasing the uptake of HCT and encouraging partner dialogue about HIV testing and going for testing together.

• Encourage pregnant women to test at an early stage in their pregnancies and seek guidance on safe infant feeding practices to protect their health and the health of their baby. Youth are a critical group in HIV prevention. More than half of the new infections around the world each day are among youth aged 15–24 years. Youth were thus a key target group for the Prevention Campaign.

Components of the Prevention Campaign

Reach of the Prevention Campaign

Zithande

Youth aged 16–24 years who were included in the nationally representative survey showed high levels of exposure to Khomanani in the past 12 months:

Khomanani recognised the significance of accelerated prevention and its key goals as reflected in the National Strategic Plan (NSP II). Through Zithande, the Prevention Campaign aims to build a sense of personal empowerment and responsibility by intensifying and strengthening the ABC strategy:

• delaying sexual activity for as long as possible • being mutually faithful • using condoms correctly and consistently The sub-campaign also aims to encourage HCT uptake, particularly among pregnant women.

Take your relationship to the next level “Take Your Relationship to the Next Level” was a component of the Prevention Campaign in Khomanani II, and continued into Khomanani III. It aimed to encourage young people to be aware of the risk of HIV in all relationships, even stable ones. It did this through promoting HCT among youth who are sexually active and among those who are considering a sexual relationship. A particular focus of the campaign was to increase dialogue between couples about HIV testing, and to encourage partners to go for testing together.

• Two-thirds (68%) had heard of the Khomanani Campaign

• Some 84% said they recognised the Khomanani logo

• Just over half (52%) had seen the word or concept “Zithande” When exposure to Khomanani was measured using a more refined measure of exposure, some 40% of young people (about 3.6 million) reported being exposed to Khomanani. Some 29% of young people in the national sample had been exposed to the “Take Your Relationship to the Next Level” sub-campaign, as indicated by their ability to complete the slogan “Take your relationship… to the next level”. This means that approximately two and a half million young people knew the slogan. In the 36 Community Action sites across the country, the national broadcasts and print materials were reinforced through various Community Action activities, for example, condom distribution, small media distribution and person-to-person education. Around 3% of young people in the national sample reported that they, or somebody

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in their household, had been visited by a KCP representative in their home.

Impact of the Prevention Campaign on Maintaining Existing Positive Behaviour among Youth In a context where most HIV transmission is through sexual intercourse, reducing new HIV infections is dependent on reducing highrisk sexual behaviour. Key sexual behaviour indicators include:

• delaying the onset of sexual debut • primary and secondary abstinence • consistent and correct condom use • partner reduction In this section, we will report the main findings on sexual behaviour, focusing largely on young people aged 16–24 years, since they were the target of the Khomanani Campaign. Findings will be compared with the 2006 evaluation so as to highlight changes in knowledge and behaviour over time.

Delaying sexual debut The evaluation survey showed levels of sexual behaviour to be very similar to those reported previously. The 2006 evaluation reported that 11% of men and 3% of women had sex before the age of 15. This evaluation survey showed similar figures. Some 8% of men and 4% of women aged 16–19 years had had sex before 15 years, while 3% of women and 10% of

men aged 20–24 years had had sex before this age. In terms of abstinence, 30% of 16–24 year-olds had never had sex, and 20% of 16–24 year-olds had not had sex in the past 12 months. These results are similar to those of 2006 where 31% of 15–24 year-olds had never had sex, and 16% of 15–24 year-olds had not had sex in the past 12 months. Overall, 84% of all young people agreed that if you wait to have sex “you will find the right person for yourself”. No significant difference in attitudes towards delaying sexual debut was noted among young people exposed and not exposed to Khomanani (p=0.35). Social norms around abstinence were also explored. A total of 37% of young people agreed with the statement: “Anyone who waits until they are older to have sex will lose most of their friends”. More young people who had been exposed to Khomanani (40%) than those who were not exposed (35%) agreed with this statement (p=0.08). This may require further explanation. Exposure to Khomanani had a significant effect on knowledge of abstinence as a way of preventing HIV transmission. When asked to name all of the ways they knew that HIV infection can be prevented, 38% of young people not exposed to Khomanani mentioned abstinence spontaneously as compared with 55% of young people exposed to Khomanani (p=0.00). As depicted in Figure 12, more young people who were highly exposed to Khomanani knew that abstinence was an HIV-prevention method than those who were not exposed or those who had low exposure (p=0.00).

Figure 12: Impact of Khomanani on knowledge of abstinence as an HIV-prevention method

60 50 40

30 20 10 0

No exposure

Low exposure

Medium exposure

High exposure

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Correct and consistent condom use Enhancing correct and consistent condom use is an important part of preventing the spread of the HIV epidemic, especially in South Africa where there are low levels of male circumcision and high levels of multiple and concurrent partnering. In this context, communication campaigns often focus on different influences on condom use, including:

â&#x20AC;˘ Knowledge of the importance of condom use as an HIV-prevention method

â&#x20AC;˘ Social norms regarding condoms

Knowledge of the importance of condoms as an HIV-prevention measure is very high in South Africa, being mentioned by 89% of young people. Exposure to Khomanani had a significant effect on knowledge of condoms as an HIV-prevention method as is evident in Figure 13 below. More young people who were highly exposed to Khomanani knew that condoms could be used to prevent HIV (89%) compared with those who had low exposure (84%) and those who were unexposed (77%) (p=0.01).

Figure 13: Impact of Khomanani on knowledge of condoms as an HIV-prevention method

100 87

90 80

84 77

70 60

No exposure

Low exposure

A multivariate analysis of the predictors of knowing that using condoms are a method for preventing HIV and controlling for a number of potential confounders was performed. This model revealed that exposure to Khomanani is associated with a 1.3 times higher likelihood of naming condoms as a method of HIV prevention (OR: 1.32, p=0.000, CI: 1.1,1.5). There has been some concern in South Africa recently about the public perception of ChoiceTM condoms, a government branded condom that is freely distributed in South Africa. Some 92% of young people had heard of ChoiceTM condoms. More young people who were exposed to Khomanani (95%), and even more who had been exposed to both Khomanani and KCPs (98%) had heard of ChoiceTM condoms (p=0.00). The extent to which respondents trusted ChoiceTM condoms did not seem to be affected by exposure to Khomanani.

Medium exposure

High exposure

When asked whether people had done anything to prevent HIV the last time they had sex, some 40% of sexually active respondents and 63% of sexually active young people said that they used a condom to prevent HIV the last time that they had sex. The Khomanani Campaign had an impact on condom use. Just over half (53%) of all people exposed to both Khomanani and KCPs used condoms at last sex to prevent HIV compared with 35% of those who were unexposed (p=0.00). This pattern was more pronounced among young people with twothirds of those exposed to both Khomanani and KCPs reporting using a condom at last sex to prevent HIV (Figure 14). However, when this was looked at using a multivariate model controlling for sex, age, education level, employment status, marital status, race, settlement type and exposure to other media channels, Khomanani did not show up to be a significant predictor of condom use (p=0.392).

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Figure 14: Impact of Khomanani on condom use at last sex to prevent HIV among the general population and young people

General population

Young people 75

80 68

64 60 40

48 35

20 0

No exposure

Exposure to Khomanani

The sexual calendar in the questionnaire also provided information about condom use with different sexual partners in the past 12 months. Some 43% of the general population and 66% of young people used a condom to prevent HIV at last sex with any partner in the past year. Condom use with any partner by exposure to Khomanani showed a similar pattern to the one depicted in Figure 14 above. Some 38% of people not exposed, 51% of people exposed to Khomanani and 56% of people exposed to both Khomanani and KCPs reporting using condoms with any partner in the past year (p=0.00). Khomanani did not have a significant effect on condom use with any partner among young people (p=0.14).

Reduction in the number of sexual partners Reducing numbers of sexual partners has been identified as a key area for future programming in order to reduce new HIV infections. This survey addressed knowledge and behaviour in relation to multiple sexual partners. The former focused on respondents’ awareness of multiple sexual partners posing a risk for HIV, and the latter focused on the number of sexual partners that people had in the last 12 months and in the last month. Respondents were asked to name the various different ways in which HIV could be prevented. Only 39% of the general population and 32% of young people spontaneously mentioned that

Exposure to Khomanani & KCP

HIV could be prevented by sticking to one sex partner. This is much lower than compared to the number of people who mentioned condoms and other forms of prevention. Khomanani did not have an effect on the number of young people who highlighted partner reduction as a prevention method (p=0.19). More young people who were highly exposed to Khomanani agreed with the statement “Having several sexual partners at the same time makes it more likely that you will get HIV” than those who were not exposed (p=0.06). However, results from the multivariate analysis indicate that Khomanani did not show to be a significant predictor of knowledge that multiple sexual partners increases the risk of getting HIV (p=0.2). Among young people aged 16–24, 14% of men and 2% of women said that they had more than one sexual partner in the last month. In the same group, 31% of men and 7% of women said that they had more than one sexual partner in the past 12 months. The Khomanani Campaign had no impact on the numbers of sexual partners listed. This is not surprising as the campaign did not focus explicitly on this issue.

Impact of Khomanani on HCT among Youth Overall, the data indicates that there has been a considerable increase in the number of young

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people who have tested for HIV. In 2006, HCT uptake among 15â&#x20AC;&#x201C;24 year-olds was 26%. Although the data is not completely comparable, this survey revealed that 51% of sexually active people aged 16â&#x20AC;&#x201C;24 had ever been tested for HIV (Table 9). Of these, 70% had tested in the last 12 months, which shows a dramatic increase in the uptake of HIV testing. Traditionally, a greater proportion of young

women have been tested for HIV when compared with young men; this is likely to reflect the fact that women are often tested for HIV during antenatal visits. In 2006, 38% of young women compared to 17% of young men had tested. This survey revealed an increased number of young people, particularly men, who had ever tested for HIV and who had tested in the past 12 months (Table 9).

Table 9: Number and percentages of sexually active young men and women having tested for HIV Males

Females

Total

Ever tested

799,144 (31.8)

1,727,317 (71.2)

2,526,461 (51.1)

Tested in the last 12 months

555,449 (70.0)

1,214,056 (70.5)

1,769,505 (70.2)

The median number of times tested among sexually active young people who had ever been tested was 2 times. Promoting HCT and knowing your HIV status was a focus of Khomanani. Although an outcome of increasing actual HIV testing was considered important, the intention was also to promote dialogue about HCT, in order

to increase risk perception among people in longer-term relationships. As can be seen in Figure 15 below, there was a clear campaign effect on dialogue and testing with partners. Young people who were highly exposed to Khomanani were more likely to have discussed testing with their partners and to have tested with their sexual partners (p=0.00).

Figure 15: Impact of Khomanani on discussing HCT and actual testing with sexual partner among young people

Asked sexual partner to test

Tested with sexual partner

20 15

17 15

10 5 0

5 1 No exposure

Low exposure

Medium exposure

High exposure

Promoting HCT and knowing your HIV status was a focus of Khomanani. 36 KHOM_IMPACT_ASSESS_06-09.indd 36

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A multivariate analysis, controlling for a number of socio-demographic characteristics and exposure to other campaigns, was conducted on the effect of Khomanani on discussing HIV testing with a partner. The results showed that people who had been exposed to Khomanani were 1.4 times more likely to have discussed HIV testing with their partner (Figure 16).

People aged between 20â&#x20AC;&#x201C;24 years and people from Mpumalanga were more likely to have discussed HIV testing with their partner. People who were most unlikely to discuss HIV testing with their partners were: men, White people, people who have never been tested for HIV and people who were not married but living with their sexual partners.

Figure 16: Predictors of discussing HIV testing with a partner

Mpumalanga

1.9

Exposure to Khomanani

1.4

20-24 years

1.4

Male

0.8

Not married but with sexual partner

0.2

White

0.2

Never been tested for HIV

0.1 0

0.5

The Khomanani Campaign was associated with young people going for an HIV test, as can be seen from Figure 17 below. Just over half of

1.5

those not exposed to Khomanani (57%) had been tested in the past 12 months compared with 71% of those highly exposed (p=0.03)

TB Day, Matlosana, North West, 2009

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Figure 17: Impact of Khomanani on HIV testing in the past 12 months among young people

80 60

Medium exposure

High exposure

65 57

40 20 0

No exposure

Low exposure

Results from the multivariate analyses revealed that people exposed to Khomanani were 1.2 times more likely to have ever had an HIV test. There seemed to be no effect of exposure to Khomanani on HIV testing in the past year (p=0.380).

Summary • Exposure to Khomanani among young people: Some 66% of youth aged 16–24 years had been exposed to Khomanani, while 29% could complete the slogan ‘Take Your Relationship to the Next Level’. Only 3% reported that they, or somebody in their household, had been visited by a Community Action ambassador at home. • Delaying sexual debut: There was no significant difference in attitudes towards delaying sexual debut among young people exposed and not exposed to Khomanani. Exposure had an effect on knowledge of abstinence as a means of HIV prevention, with 55% of those exposed to Khomanani compared with 38% of those unexposed, mentioning abstinence. • Correct and consistent condom use: Over 80% of exposed young people and 77% of unexposed young people knew that condoms were a method of HIV prevention. Exposure to Khomanani was associated with a 1.3 times higher likelihood of naming condoms as an HIV-prevention method. An association between exposure to Khomanani and condom use at last sex was present with 53% of all people exposed to both Khomanani and

Khomanani community partnership (KCPs) using condoms at last sex, when compared with 35% of those unexposed. That said, exposure to Khomanani did not appear to be a significant predictor of condom use. • Partner reduction: People exposed to Khomanani were more likely to mention partner reduction as an HIV-prevention method – although this was not the case among youth. A multivariate analysis showed that exposure to Khomanani had no effect on people’s knowledge that having multiple sexual partners puts you at greater risk of getting HIV. As for sexual behaviour in relation to exposure is concerned, analysis suggests that the Khomanani Campaign had no impact on the number of sexual partners listed by respondents. This is not surprising as it was not a focus of the Khomanani Campaign. • HCT among youth: Khomanani had a positive effect on young people’s dialogue and testing with their partners, and exposure to Khomanani showed up a significant predictor of discussing HIV with a partner. Some 71% of young people who were highly exposed had been tested in the past 12 months, when compared with 57% of those not exposed. A multivariate analysis showed that people exposed to Khomanani were more likely to have ever been tested for HIV compared with those not exposed. However, there was no effect on number of people in the general population who were tested in the past 12 months.

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Treatment, Care and Support Campaign This Treatment, Care and Support (TCS) Campaign intended to popularise and promote knowledge of the CCMTSP of the DoH and increase care and support for OVCs.

The campaign aims to acknowledge and recognise the following:

• Care and support for people infected and affected by HIV and AIDS • ARV treatment is a lifelong commitment • Talk openly about HIV and AIDS, STIs and TB • Support children in need of care and protection • Anti-retroviral treatment and good nutrition can prolong and improve your life

Components of the TCS Campaign Support for CCMTSP The CCMTSP is a programme that promotes a package of support for people living with HIV, and extends from supporting those affected by HIV and AIDS to ART. Initially the focus of the campaign was intended to be on ART, as it is a complex treatment, and requires high levels of compliance by patients. It is estimated that patients need to be 95% adherent to their treatment to stop the virus becoming resistant to the ARV drugs. To get to this level, there needs to be a combination of patient education and community and family support. Specific campaign goals included:

• Increasing treatment literacy • Increasing knowledge about the CCMTSP programme

• Increasing community support for the programme

• Increasing the support of communities for people infected and affected by HIV and AIDS

Caring Together For Children One of the most devastating consequences of the HIV epidemic is the large number of children who are orphaned as a result of their parents dying of AIDS. The needs of OVCs include basic material needs such as food, shelter and

clothing. However, children also need access to psychosocial support and education, which is essential if they are not going to be trapped in the cycle of poverty. The South African Government has a number of social grants that can support OVCs, including the Child Support Grant and the Foster Care Grant. However, access to these grants is hindered by bureaucratic delays, and not all OVCs will be eligible for a government grant. The scale of the problem of OVCs means that the response that is needed is beyond the capacity of any single government department or organisation. Entire communities need to be mobilised to assist these children to meet their needs. The Caring Together for Children component of the TCS Campaign aimed to increase individual and community support for children in need. It encouraged communities to adopt the attitude that “every child is my child” and to assist children in need to care and protection.

Reach of the TCS Campaign Some 11% of the national population, or about 3 million people, had been exposed to both Khomanani and the OVC advert on helping children in need or Caring Together for Children. Exposure to Khomanani and Caring Together for Children was lowest among older people as well as people in peri-urban and farming settlement types.

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Impact of the TCS Campaign Impact of Support for CCMTSP Knowledge of ARV treatment has improved dramatically. Some 87% of the population knew that ARVs are a treatment for HIV, and 73% knew that treatment was for life. These figures were much higher than the figures reported in the 2006 survey (42%). As shown in Figure 18 below, exposure to Khomanani had a significant effect on knowledge of ARVs (p=0.00).

It is believed that if people have a true understanding of the science behind treatment, then they will have greater adherence to the treatment. It is also thought that a better understanding of treatment will encourage and support prevention strategies. This is based on the premise that people will better understand how to reduce their risk of infection and better adhere to treatment. The importance of treatment literacy is also built upon the belief that treatment knowledge will encourage people to seek treatment and service delivery.

Figure 18: Impact of Khomanani on treatment literacy indicators

Not exposed 100 80

Exposed 83

93 70

60 40 20 0 Know there is a treatment for HIV

Named ARVs as a treatment

Know treatment is for life

variety of potential confounders was performed on this outcome, people exposed to Khomanani were 0.16 times less likely to have cared for someone living with HIV and AIDS (OR: 0.84, p=0.02, CI:0.73;0.98). This finding cannot be explained and may require further investigation.

Multivariate analyses were conducted on both knowledge of treatment for HIV and AIDS (treatment was defined as something to keep you healthy and not a cure for the disease) and knowledge that ARV treatment is for life. Socio-demograhic characteristics and exposure to other campaigns were controlled for. People exposed to Khomanani were 1.5 times more likely to know that there is a treatment of HIV, and 1.4 times more likely to know that ARV treatment is for life. Exposure to Khomanani had a similar effect on peopleâ&#x20AC;&#x2122;s knowledge of ARV treatment as exposure to other campaigns did.

Impact of Caring Together for Children

Some 16% of the population had ever helped take care of anyone who was sick with AIDS. Khomanani also aimed to increased support for PLWHAs. More people exposed to Khomanani, Caring Together for Children and KCPs (28%) had cared for someone sick with AIDS than those who were unexposed (15%) (p=0.00). However, when a multivariate analysis controlling for a

However, a multivariate analysis revealed that exposure to Khomanani was not a significant predictor of whether people had personally helped care for an orphan whose parents died of AIDS (p=0.08). This finding may also require further investigation.

Some 10% of the population had personally helped care for orphans whose parents died of AIDS in the past 12 months. As shown in Figure 19 below, exposure to Khomanani, Caring Together for Children and KCPs was associated with an increase in care and support for children affected by AIDS (p=0.02).

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15 10

13 10

5 0

KHOM_IMPACT_ASSESS_06-09.indd 41

No exposure

Exposure to Khomanani OVC

Exposure to Khomanani OVCs & KCP

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Tuberculosis Campaign Tuberculosis (TB) is an opportunistic infection that adds to the burden of illness of HIV-positive people and shortens life expectancy. Khomanani embarked on a TB sub-Campaign, ‘Hola 6’. This sub-campaign focused on increasing knowledge on TB and HIV co-infection, increasing treatment literacy on TB and HIV, and increasing compliance and adherence to TB treatment.

The Hola 6 Campaign aimed to create awareness that TB is curable. It aims to encourage people to seek help for TB and to successfully complete treatment. The campaign aims to build a sense of personal empowerment and responsibility through:

• Increasing knowledge on TB and HIV co-infection • Increasing treatment literacy on TB and HIV • Increasing compliance and adherence to TB treatment

Impact of the Hola 6 Campaign Some 78% of people knew that TB treatment was for 6 months. Knowledge was quite similar among all age groups with the exception of 16–19 year-olds, of which only 69% knew that TB treatment was for 6 months compared to approximately 80% of people in other age

groups. Some 78% of people also knew that TB infection was more likely in PLWHAs. However, when asked to identify the following statement as true or false “It is not possible to cure TB in people who are HIV positive”, less than half of the population correctly answered that this was false. This can be seen in Figure 20.

Figure 20: Percentage of respondents correctly answering various questions about TB

100 80

40 20 0

TB treatment is 6 months

Someone who is HIV positive is more likely to get TB

The Hola 6 Campaign was successful in conveying information about TB treatment duration. Considering the high prevalence of HIV and TB co-infection, knowledge of correct treatment is very important. In 2004, only 2% of people knew that TB treatment was for six months. By 2006, 77% of the people knew the duration of TB treatment. In 2009, this

It is not possible to cure TB in patients with HIV

knowledge further increased to 83% of the people exposed to the intervention. A multivariate analysis revealed that people exposed to Hola 6 were 1.5 times more likely to know that TB treatment is for 6 months than people who are not exposed (Figure 21).

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Figure 21: Predictors of knowledge that TB treatment is for 6 months

45-49 years

2.2

KwaZulu-Natal

2.0

40-44 years

1.9

Tertiary education

1.5

Exposure to Hola 6

1.5

Exposure to Scrutinize

1.3

Exposure to Tsha Tsha

1.2

Gauteng

0.7

Male

0.7

White

0.3 0

0.5

When asked whether PLWHAs are more likely to get TB than someone who is HIV negative, the percentages of people who answered correctly were similar in both the exposed and unexposed groups (79% exposed and 78% unexposed). The impact of the Hola 6 Campaign did not seem to have shown an effect on knowledge of co-infection. A multivariate analysis confirmed that there was no significant increase in knowledge of this item by exposure to Hola 6 (p=0.621). Approximately 51% of those exposed to Hola 6 believed that it is possible to cure TB in PLWHAs, as opposed to 49% of those who were unexposed.

1.5

2.5

Summary â&#x20AC;˘ Knowledge of duration of treatment: Exposure to Khomanani had an effect on knowledge of duration of TB treatment with 83% of exposed people knowing that TB duration is six months. Knowledge of this item has shown a steady increase since the launch of the Hola 6 Campaign.

â&#x20AC;˘ Knowledge of TB and HIV co-infection: Over half of people knew that TB is more likely in PLWHAs as compared to unexposed people (49%). However, some 50% of respondents did not know that TB is curable in PLWHAs. Exposure to Khomanani did not have an impact on this knowledge. There is potential room for improvement in messaging around curability of TB in PLWHAs.

Over half of people knew that TB is more likely in PLWHAs as compared to unexposed people (49%).

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Nutrition and Health Promotion Campaigns The Nutrition Campaign focused on the importance of nutrition as part of the comprehensive package of care for people living with HIV and AIDS. This campaign aimed at improving knowledge of nutrition and its importance in improving quality of life. Health Promotion cut across all of the campaigns. Its conceptual framework encouraged healthy lifestyles, physical activity and healthseeking behaviour. The questionnaire used in this evaluation did not measure all of the objectives falling under the Nutrition and Health Promotion campaigns. Information about selected objectives is presented in the sections below.

Nutrition Campaign Among other things, the Nutrition Campaign focused on PMTCT. Its goal was to raise awareness that HIV can be transmitted from mother-to-child through breast milk but can be prevented through exclusive breastfeeding or by feeding the baby with formula only. This campaign aimed at building a sense of personal empowerment and responsibility through:

• Encouraging exclusive breastfeeding, even in cases of mothers being HIV positive

• Promoting exclusive infant feeding practices according to AFASS principles, such that replacement feeding is Acceptable, Feasible, Affordable, Sustainable and Safe

Respondents were asked whether the following statement was true or false: “HIV-positive women can transmit HIV to their babies through breast milk”. More women (83%) correctly identified this statement as true as compared to men (78%) (p=0.00). Fewer people in urban informal settlements knew about MTCT (75%) when compared to other settlement types. Exposure to Khomanani had an impact on people’s knowledge of MTCT through breast milk. Some 78% of people who were not exposed to Khomanani knew that HIV could be transmitted through breast milk as compared to 91% of people exposed to both Khomanani and KCPs (p=0.00). Khomanani had an even greater impact on women – who were its primary target group – as depicted in Figure 22 (p=0.00).

Figure 22: Percentage of women who know that HIV can be transmitted through breast milk

100

95 87

90 80

70 60

No exposure

Exposure to Khomanani

Figure 23 shows that people who were exposed to Khomanani were 1.4 times more likely to know that HIV can be transmitted through

Exposure to Khomanani & KCP

breast milk than people who were not exposed (P=0.00, CI: 1.2;1.6).

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Figure 23: Predictors of knowing that HIV can be transmitted though breast milk

Exposure to Khomanani

1.4 1.3

High socio-economic status Employed

1.3

Male

0.7

North West

0.6

Indian

0.6 0

This survey also looked at the ways people knew MTCT could be avoided. Spontaneous mention of infant feeding options was very low. Fewer

0.5

1.5

people knew about exclusive breastfeeding as compared to formula feeding as depicted in Table 10 below.

Table 10: Percentage of people knowing that formula feeding and exclusive breastfeeding can prevent MTCT Males

Females

Total

Formula feeding

10.5

19.1

14.9

Exclusive breastfeeding

1.1

2.2

1.7

Khomanani had a mixed impact on knowledge of infant feeding options. Women who were exposed to Khomanani and KCPs were more likely to know about formula feeding as a way of preventing MTCT (p=0.00). However, exposure to Khomanani did not affect knowledge of exclusive breastfeeding (p=0.66).

Health Promotion Campaign The Health Promotion Campaign encouraged healthy lifestyles, physical activity and healthseeking behaviour. One of the key issues this campaign addressed was substance abuse.

This campaign promoted awareness about the dangers of substance abuse both for oneself and for others. The questionnaire included questions about alcohol use and the frequency of respondentsâ&#x20AC;&#x2122; visits to places where alcohol is served. People were asked how often they had drunk heavily in the past month; for men this constituted having consumed 5 drinks or more drinks on one occasion and for women this was four or more drinks. As shown in Table 11 below, almost 2% of the population drank heavily every day.

This campaign promoted awareness about the dangers of substance abuse, both for oneself and for others.

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Table 11: Percentage of people drinking heavily in the past month Total Never

21.1

Hardly Ever

18.7

Less than once a month

22.9

A few times a month

20.8

Almost every week

14.6

Almost every day

1.9

Some 18% of people had visited a shebeen, bar, tavern and/or nightclub in the past month where alcohol was served. Of these, 7% reported ending up having sex with someone they met at a shebeen. Exposure to Khomanani did not show any significant impact on the following:

• the frequency of heavy drinking • visiting places where alcohol was served • having sex with someone who was encountered at a place where alcohol was served.

Summary • Knowledge of infant feeding options: Exposure to Khomanani had an effect on knowledge that HIV can be transmitted though breast milk. This effect was particularly evident in Khomanani’s message target group – women. However, Khomanani had a mixed impact on knowledge of infant-feeding options. Women who were exposed to Khomanani and KCPs were more likely to know about formula feeding as a way of preventing MTCT, but exposure to Khomanani did not affect knowledge of exclusive breastfeeding.

• Alcohol use: Exposure to Khomanani did not show any significant impact on the frequency of heavy drinking, visiting places where alcohol was served or having sex with someone who was encountered at a place where alcohol was served.

The Programme Director of Khomanani (and Director GAAP: HIV & AIDS and STIs) handing a cheque to Thembeni: Place of Hope for the babies in need of care and protection SOS Village.

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General Conclusions The Khomanani Campaign is an innovative comprehensive HIV and AIDS communication campaign that embraced different themes across a wide variety of media channels. The campaign evaluation used a strong study design. It has generated a large amount of invaluable data on indicators of relevance to understanding the impact, not only of Khomanani, but also of other HIV and AIDS behaviour-change communication interventions in South Africa. The following conclusions can be drawn:

Reach of Khomanani has continued to grow and quite a large number of people recognise the campaign now However, it is difficult to interpret logo and name recognition since the campaign has been around for seven years. As shown by the number of people who knew that Zithande was about HIV and/or were able to complete the slogan, fewer people know what a campaign like Zithande means.

There is still a gap between people discussing HIV testing and the number of couples actually going for an HIV test together This may have to do with barriers at an individual, community or health-service level. Given the importance of normalising HIV testing in relationships, both HIV prevention and AIDS care, this is a campaign that should be continued.

Exposure to Khomanani was associated with some important and significant shifts in knowledge, attitudes and behaviours related to HIV prevention

Khomanani was also associated with some important changes in treatment, care and support

• Knowledge: Exposure to Khomanani was

• Knowledge: Exposure to Khomanani showed

associated with an increase in knowledge of abstinence, condoms and partner reduction as methods for HIV prevention.

• Behaviour: Exposure to Khomanani was associated with lower-risk behaviour, such as increased condom use at last sex. Khomanani also had a positive effect on young people’s dialogue and testing with their partners.

Some important HIV prevention messages have not been addressed This is shown by lack of impact. This is particularly the case for numbers of sexual partners. This is an important area to consider for future campaigns, but like all communications, the target audience and the creative strategy needs careful consideration. Further analysis of the data from the sexual calendar may be useful in identifying the characteristics of people who have MCP, and this can then be used to inform future campaigns. Another area where Khomanani had no impact was on positive attitudes towards delaying sexual debut. This is an important area to target in the future, especially among youth.

significant increases in knowledge of treatment literacy. This is encouraging given government’s goals of putting 1 million people on treatment. Treatment literacy messaging should be continued in order to maintain the levels of knowledge seen in this survey.

• Behaviour: More people exposed to Khomanani cared for a child whose parents died from AIDS than those who were unexposed. Given the difficulties faced by OVCs, community support is vital and these positive findings indicate that Caring Together for Children is starting to be effective.

There were also areas where Khomanani had little impact There appeared to be a negative association between exposure to Khomanani and support for PLWHAs. This finding is difficult to explain and may require further exploration before adjusting the campaign focus.

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The TB (‘Hola 6’) Campaign has consistently been one of the successes of the Khomanani Campaign This continues to be the case – with more people knowing about the duration of TB treatment. However, there was no impact on the number of people knowing about curability of TB in PLWHAs. In the future, TB and HIV co-infection may need to be emphasised further as part of this campaign.

Impact of the Nutrition and Health Promotion campaigns was mixed While exposure to Khomanani was positively associated with an increased knowledge about MTCT of HIV through breast milk and

of formula feeding as a preventative strategy, there was no association with knowledge of exclusive breastfeeding. Future campaigns will need to focus on exclusive breastfeeding as well as formula feeding as preventative strategies so that women can make informed decisions about infant feeding. This will also contribute towards government’s aim of reducing MTCT to below 5% by 2011. One of the focus areas of the Health Promotion Campaign was alcohol use. This was another area where Khomanani did not show any impact. It is critical that future campaigns address social norms around alcohol use.

Reach of Khomanani has continued to grow and a large number of people recognise the campaign now

Kick TB bus, Kick TB roadshow, 2010

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Annexures Annexure 1 Comparison of the 2009 National AIDS Communication sample with the 2007 Statistics South Africa Community Survey on selected variables Variables

NCS 2009

Stats SA 2007 Estimates (per cent)

Not weighted (per cent)

Weighted by Population Frequencies (per cent)

Weighted by Population Frequencies

Male

45.6

48.7

13,360,977

48.7

Female

54.4

51.3

14,049,674

51.3

16–24 years

38.7

32.3

8,864,781

31.9

25–49 years

54.8

59.3

16,261,810

58.6

50–56 years

6.5

8.3

2,284,060

9.5

Black

81.6

77.8

21,253,637

77.6

Coloured

12.4

9.5

2,590,313

9.5

White

4.4

9.9

2,706,899

10.0

Indian

1.5

2.8

7,75,012

2.9

Western Cape

7.9

11.6

3,186,673

11.6

Eastern Cape

11.9

3,250,281

11.9

Free State

8.8

5.9

1,609,441

5.9

Gauteng

17.2

24.2

6,630,405

24.2

KwaZulu-Natal

16.0

20.5

5,611,728

20.5

Limpopo

13.6

9.5

2,610,894

9.5

Mpumalanga

10.9

7.4

2,020,460

7.4

North West

5.2

6.9

1,886,942

6.9

Northern Cape

8.6

2.2

603,827

2.2

Total

100.0

27,410,651

27, 754,287

Gender

Age Group

Race

Province

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Annexure 2 Supplementary Tables of Socio-demographic Variables Table 12: Household wealth index by race group Black

Coloured

White

Indian

No.

Hot running water

1,219

15.4

427

35.5

400

93.0

140

95.9

Microwave oven

2,419

30.5

579

48.1

387

90.2

138

95.2

Flushing toilet 3,578 in house or on plot

45.2

945

78.6

424

98.6

144

98.6

VCR/DVD player in home

4,195

52.9

724

60.2

391

90.9

125

85.6

Washing machine

1,329

16.8

632

52.5

400

93.0

112

76.7

Personal computer at home

784

9.9

199

16.6

296

69.0

51.4

TV in household

5,780

72.9

983

81.7

417

97.0

141

96.6

Radio in household

6,066

76.5

804

66.8

402

93.5

136

93.2

Land line

469

5.9

235

19.5

207

48.3

52.7

Built-in kitchen sink

1,967

24.8

656

54.5

396

92.1

136

93.2

Water in home or on stand

4,935

62.3

1,044

86.8

427

99.3

141

96.6

Electricity in household

6,433

81.2

1,085

90.2

424

98.6

146

100.0

Motor vehicles in household

1,438

18.2

283

23.5

373

86.7

112

76.7

Cell phone in household

6,640

84.0

873

72.6

406

94.6

142

97.3

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