The O Icheke Campaign, Botswana

HIV and Multiple and Concurrent Sexual Partnerships in Botswana

According to UNAIDS, HIV prevalence among 15- to 49-year-old
adults in Botswana is the second highest in the world (UNAIDS 2008). Prevalence is higher among females (20 percent) than among males (14
percent) (Central Statistics Office [CSO] 2009) and increases sharply
with age, peaking between the ages of 30 to 45. Among individuals 40 to
44 years old, prevalence is 41 percent (CSO 2009).

The rates of MCP in Botswana are also among the highest in the world. A recent analysis of Population Services International (PSI) data by University of Washington Professor Martina Morris, an expert on MCP, found MCP rates of 17.5 percent, with men and women practicing MCP at almost the same levels (PSI 2010).

MCP is deeply rooted in Botswana's society and culture. Numerous sayings acknowledge and support the behavior, such as, "A man can't be contained in one kraal (cattle enclosure)" and, "Only a mother knows her child's father." Until recently, the behavior was not widely discussed.

Although not conclusive, there is growing evidence that MCP is a major driver of the HIV epidemic in Eastern and Southern Africa (Epstein 2007; Gregson et al. 2002; Guwatudde et al. 2009; Halperin and Epstein 2007; Mah and Halperin 2010; Morris and Kretzschmar 1997; Msuya et al. 2006; Potts et al. 2008; see Box 1). The Government of Botswana believes that reducing MCP will lower HIV incidence and thus reduce the threat of HIV to the people of Botswana.

The Build-Up to the O Icheke Campaign

In May 2006, national leaders in the region convened for a Southern African Development Community (SADC)/Joint United Nations Programme on HIV/AIDS (UNAIDS) think tank meeting, at which they reached the following conclusion: "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" (SADC 2006).

Development and Implementation

Campaign Approach and Messages

The campaign aims to be different from earlier programs. Although it is a national campaign with strong mass media support, it is implemented in the districts through numerous capable community-based organizations (CBOs; around 50 of which have been trained to deliver interpersonal communications interventions). In addition, community interventions are linked to the national mass media by using the same branding, messages, and tools. One collective body developed both the mass media interventions and the tools used by the CBOs, which facilitate the standardization of messages. O Icheke's stakeholders exhibit a high level of commitment to and passion for the campaign, which enhances program excitement and sustainability.

Studies show that Batswana practice MCP for four major reasons (NACA 2009a):

• To avoid circumstantial abstinence (physical separation from primary partner, primary partner is pregnant or has recently given birth, transition between relationships)
• To enjoy sexual variety
• To experience material gain
• To find a serious or stable partner.

Because of this diversity of individual motivations for engaging in MCP, the O Icheke campaign provides not one but several sets of phased messages. The original plan was a six-phase design; each phase would run for six months, with messages changing to ensure their freshness. However, the original plan had to be modified, based on realities in the field such as working with multiple stakeholders and funding, to a one-phaseper- year schedule. The three groups targeted were young women aged 18 to 24 engaged in MCP for personal or material gain, men aged 25 to 35 engaged in MCP for sexual variety, and older men and girls engaged in cross-generational sexual partnerships.

Table 1 shows the initial phasing proposed for the campaign. The campaign plan describes how the phases evolve for both young women and adult men over the course of the campaign, and how the messages should address barriers and motivators to behavior change.

Mass media activities: The mass media interventions for Phases 1 and 2 included billboards, radio testimonials, television spots, and leaflets. Before the launch of Phase 1, a teaser campaign ("Who's in Your Sexual Network?") stimulated dialogue about MCP. Although it was originally planned to run for only one month, the teaser campaign was so successful that it was extended to six months. In March 2009, Phase 1 began, initially including both the teaser tagline and the O Icheke branding ("O Icheke—Break the Chain"). This capitalized on the sensation that was created with the teaser campaign.

Phase 2 of the mass media campaign began in June 2010 with a focus on personalizing risks, highlighting the costs and benefits of MCP, and addressing the reasons people give for engaging in it, based on earlier research. The campaign team is also exploring innovative ways to reach individuals in rural areas, because research shows that the campaign has been more successful in reaching urban rather than rural audiences.

Other mass media programs, both officially part of the O Icheke campaign and outside of the campaign, have fueled community discussion about MCP. One key program has been the popular radio serial drama, Makgabaneng, which airs episodes twice weekly and features a weekly 45-minute call-in show; it is supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The program periodically hosts community health fairs attended by the show's stars, which draw huge crowds. In April 2010, a PEPFAR-supported TV series called Morwalela aired for the first time. Set within a fictional Botswana village, it brings to life the sexual networks that exist within society and the risky behaviors they support. The O Icheke campaign has given people a means to start discussing difficult issues relevant to MCP.

Community-level reinforcement: To fulfill the goal of a fully integrated HIV/AIDS program rather than a stand-alone MCP campaign, three different types of organizations have implemented community-level activities that reinforce the O Icheke campaign. These include one-on-one sessions, group discussions, dramas, testimonials by PLWH, community and church events, youth clubs at schools, and poetry/music groups.

First, nongovernmental organizations (NGOs) and civil society organizations (CSOs) already supported by PEPFAR and ACHAP have implemented new MCP programs or integrated MCP messages into existing activities, both before and early in the campaign. Second, with World Bank funding, NACA is supporting CBOs to implement MCP activities.

Third, the Ministry of Local Government (MLG) district offices are rolling out the campaign in stages at the district level. During the first year of the campaign, 10 districts with high HIV prevalence and a substantial number of local NGOs implementing prevention activities were selected for the initial roll-out of MCP activities and messages. Those 10 districts were the first to create district campaign teams, develop district MCP plans, receive training, and become fully responsible for district campaign activities. Ahead of schedule, by the end of the first year, NACA had worked with all 30 districts to put plans for each one in place.

These three modes of community-level reinforcement have enabled many organizations to implement MCP activities by providing them with the knowledge, skills, and tools necessary to address the challenging topic of MCP at the local level. For example, one of the tools used by community-based programs to help people understand the impact of MCP on the epidemic is a simple piece of felt onto which pictures of men and women are attached. The outreach worker tells a story about the figures and uses lines, which also adhere to the material, to display how they are connected through their sexual relationships. One individual may have only one partner, a couple may have two, and another may have several partners. Soon, it becomes clear that all of these individuals are linked—that all individuals are at risk of becoming infected with HIV if the virus is introduced into the sexual network. Discussions then facilitate understanding about the acute phase of infection, during which risk of transmission is high, and about how reducing just one sexual partner helps to break infection pathways. Building on mass media messages, this is one simple intervention that may bridge the gap between knowledge and self risk assessment on the path to behavior change.

Integration into other HIV and AIDS services: One of the pillars of the O Icheke campaign is the integration of MCP messaging into HIV-related services housed in the health sector, such as antiretroviral therapy (ART), voluntary counseling and testing (VCT), treatment of sexually transmitted infections, and PMTCT services. While implementation of this key campaign component has been slower than anticipated, in March 2010 the National Couple Counseling and Testing campaign launched new communications efforts that highlight the role of MCP on HIV transmission risk in a relationship.

National-level coordination: NACA coordinates the campaign at the national level with a four-member team. NACA is responsible for introducing stakeholders at the national and district levels to the campaign and its materials. NACA also trains local organizations on MCP and on how to use the materials that will support them in implementing their activities. Currently, the team has trained most government sectors and is now training local organizations to mainstream MCP messages into their existing activities.

NACA is working to standardize messages as the campaign rolls out to the district and community levels through various means (see Box 2) to ensure that consistent and clear messages are disseminated. Campaign materials have given organizations and their staff the tools needed to start discussing how and why having more than one partner at the same time accelerates the spread of HIV. New information about acute infection and highly linked sexual networks has given individuals at the community level a wake-up call on MCP.

What Worked Well

Nationwide, multilevel coverage: Few countries have attempted to implement a national HIV prevention effort focused on behavior change. Most prevention efforts are small-scale and fragmented. Botswana is a pioneer in its efforts to lower HIV incidence by implementing a national behavior change communication campaign led by the national government with overwhelming support from leaders. It is multifaceted in terms of having multi-leveled interventions (national, district, local, and clinical) implemented by numerous stakeholders through existing structures (such as district offices run by MLG).

Stimulating discussion: The campaign has fueled lively national discussion about MCP throughout the general population. Private radio stations and newspapers have independently hosted talk shows and published stories about MCP. A youth independent of the campaign created an O Icheke Facebook page to encourage others to reduce concurrency. The O Icheke campaign has given people an easier way to talk about a difficult topic. The large-scale success in stimulating discussion about MCP at the societal level in a relatively short period of time is one achievement of the campaign.

Strong national leadership: Significantly, the O Icheke campaign is driven by the national government and not by an international donor. The campaign has strong national leadership and the support of President Ian Khama, Parliament, NACA, and other ministries, as well as the House of Chiefs, a political body of tribal leaders in Botswana. President Khama speaks publicly about MCP, a subject many other African leaders have not broached. The engagement of national leaders has brought discussion of MCP and related issues to an unprecedented level, surprising even the campaign team.

Stakeholder commitment at all levels: The O Icheke campaign has a strong identity. It has created excitement among the implementing partners, and many organizations at all levels (national, district, and local) want to be part of the campaign. Many perceive the campaign as an exemplary multilevel communication effort. The majority of districts are enthusiastic about implementing activities tied to the O Icheke campaign. Most stakeholders report that the campaign's reach and coverage are excellent and that it is visible in most urban and peri-urban areas. Many also feel that this high-level attention to MCP is overdue.

A strong evidence base: The campaign was built on a strong evidence base, and the national leadership is highly supportive of the ongoing collection of data. Available data can inform the further refinement of the campaign. The midterm and final evaluations will aim to make correlations between the campaign and the behaviors of the target populations.

Challenges

Roles and project ownership: Various government agencies are tasked with different aspects of the O Icheke campaign. The Ministry of Health (MOH) and NACA each have key roles in the campaign. NACA initiated the O Icheke campaign and is responsible for coordinating the stakeholders for implementation. NACA has a mandate to carry out advocacy activities, conduct training, and provide necessary funding to partners. These mandates support partners and ministries as they implement MCP activities, which include health sector mainstreaming and service provision. The MOH oversees the health response to HIV and is charged with mainstreaming MCP into the health sector programs, such as couples testing, VCT, ART, and PMTCT. The Ministry of Education is responsible for implementing the life skills program in schools, and the MLG is charged with rolling out the campaign at the district level.

The O Icheke campaign has given people an easier way to talk about a difficult topic.

Despite these mandates, MOH leaders felt left out of the initial campaign process and criticized NACA for bringing them into the campaign at the same time as the other stakeholders. NACA officials and other stakeholders say that the MOH was invited to participate in the campaign from the start and had a representative at the initial meetings. In any case, the MOH still perceives the campaign as a NACA initiative and feels little ownership of it. One of the pillars of the campaign is to integrate MCP messages into other HIV and AIDS services for which the MOH holds responsibility. The institutional rivalry between NACA and the MOH has hindered this activity.

Two actors from the Makgabaneng Radio Program depicting a scene on MCP.

Rolling out the campaign to districts: The mass media interventions at the national level were implemented on schedule, and the majority of stakeholders agree that this portion of the campaign is strong and engaging. NACA reported that by February 2010, on-the-ground MCP interventions had taken place in the majority of districts, implemented both by local CBOs and through the district structures. NACA also reported that the district roll-outs were quicker than anticipated due to World Bank funding and district interest. However, many stakeholders feel that the implementation of community-based or interpersonal interventions at the local level has been slow.

The stakeholders' perception of the slow campaign roll-out could stem from the normal pace of distributing funds and planning and launching activities. It takes time for funds to be allocated, CBOs to be identified and trained, and activities to be implemented. The limited reach of community-based activities could be another reason for this perception.

Insufficient funding: When the campaign plan was first written and an initial budget was drafted, all of the activities the team thought necessary for the campaign were included. The final cost of the campaign far exceeded available resources, so it had to be scaled back. NACA did secure additional resources, such as funding from the World Bank, but has not yet been able to mobilize the originally budgeted amount.

Growing civil society: Although outside the mandate and responsibility of the O Icheke campaign, the strength of a still-growing civil society in Botswana affects its overall impact. Botswana has a strong central government that provides both services for its population and funding to organizations, so a vibrant civil society is still emerging. Numerous local NGOs have been developing their capacity over the past several years, and this is one reason the districts could roll-out MCP activities so quickly. However, the campaign still needs more high-capacity CBOs and NGOs to work with to improve the coverage, reach, and quality of programs.

Monitoring and evaluation: There is an international call for evidence linking MCP interventions with behavior change. MCP is an emerging area in the field of HIV prevention, and definitions and measurements are continually being improved. Botswana must try to measure the campaign's impact, even as these indicators of success continue to be defined.

Monitoring current activities was also seen as a challenge to many organizations. Because CSOs have limited capacity, it is unclear whether they have been able to adequately monitor their interventions. Local organizations require monitoring tools and support to effectively track, revise, and improve their programs.

Sustainability: The unusual level of stakeholder interest in the campaign will require constant nurturing. The campaign will need to maintain the current momentum and excitement to ensure its sustainability.

Recommendations

Involve key stakeholders from the beginning: It is vital to include and actively involve all key stakeholders in a national campaign, from the initial brainstorming sessions to actual planning and implementation. The O Icheke campaign is a national campaign that strives to involve all key national, district, international, and local partners, a challenge few countries have attempted. The overall success of a national program hinges on active participation, support, and ownership of all partners.

Schedule mass media and on-the-ground interventions close together:Simultaneous roll-out of interventions may be unrealistic, but if community interventions are introduced shortly after the implementation of mass media activities, individuals will have a source for answers to questions and a place to discuss concepts presented in the publicity campaign.

Because numerous factors contribute to the practice of MCP, a series of phases and messages may need to be implemented at the same time to be effective. Thoughtfully branded and complementary messages can bridge the gap between mass media and community-based activities.

Focus on a smaller number of phased messages addressing individual or community needs: One lesson learned from the O Icheke campaign is the need to focus on a smaller number of campaign phases and messages. Although six phases were originally planned at the inception of the campaign, funding and rolling out the campaign into the districts took so long that only one phase could be implemented per year. A longer timeline per phase is necessary, especially given the time needed to implement change on social norms and the reality of involving numerous stakeholders in message development. Similar national programs should plan for more modest numbers of phases or messages to accommodate the complexities of working with multiple stakeholders and multiple funding cycles.

Also, mass media and community-level interventions may need different phase content. For example, the communities may discuss MCP issues that the mass media interventions have not broached. The phases should be determined by the districts and by those implementing the interventions based on the knowledge, perceptions, and needs of the community.

Future Programming

As the campaign moves into its second year, the campaign coordination unit at NACA has been charged with 1) focusing on the districts to ensure that MCP is fully integrated into district campaign plans and that all elements in the district are coordinated, and 2) ensuring integration of MCP into the materials and programs of key ministries and organizations (for example, working with MOH to integrate MCP into ART program materials). In addition, as new data emerge, the campaign may need to change direction to fill emerging gaps. For example, target populations could shift based on the results of the campaign's impact study.

Two of the biggest issues for the campaign team will be developing strong messages through pre-testing and revision and supporting both the district teams and local NGOs and CSOs in implementation as the campaign ramps up in the districts. Messages will need strengthening as future phases introduce concepts that are more nuanced and complex and as target populations begin to more fully understand the risks associated with MCP. In addition, as the campaign rolls out in the districts, new implementation issues will emerge, such as ensuring message and intervention quality; providing ongoing training, supervision, and oversight; maintaining a balance between standardization and local adaptation of messages; and ensuring that correct information about MCP is conveyed. The campaign will also need to address the capacity of district-level employees to deal with these issues locally.

Because numerous factors contribute to the practice of MCP, a series of phases and messages may need to be implemented at the same time to be effective. Thoughtfully branded and complementary messages can bridge the gap between mass media and community-based activities.

The roles of NACA, MLG, and MOH need to be continually clarified and strengthened to develop a more constructive partnership in the campaign. The relationship between NACA and MLG is essential for successful district-level roll-out of the campaign. If overall integration of MCP messages is to be achieved at all HIV and AIDS service delivery points, the relationship between NACA and MOH needs to be strengthened.

O Icheke has wide support from a number of stakeholders, and there is considerable excitement about the campaign. The term O Icheke has given people a "codeword" to initiate discussion on a difficult topic. Many Batswana are surprised to learn that having just two sexual partners at the same time puts people at increased risk of HIV infection. New information on acute infection and how HIV can be easily transmitted within sexual networks is changing how people assess their HIV risk. The overwhelming media coverage and public discussion of MCP demonstrate the social relevance of the topic.

NACA and the campaign team are aware of the considerable challenges in implementing an innovative national campaign and continue to discuss and devise ways to address them. The Government of Botswana hopes that this ambitious, integrated HIV prevention effort will have the necessary impact on lowering HIV incidence in a country with some of the highest HIV prevalence in the world.

RESOURCES

AIDSTAR-One. 2008. Meeting Report for Multiple and Concurrent Sexual Partnerships Event/Presentations.

AIDSTAR-One. 2010. Behavioral Interventions: Multiple and Concurrent Sexual Partnerships. AIDS Support and Technical Resources, Prevention, Behavioral Interventions.

O Icheke Facebook Page . (accessed July 8, 2011)

PSI/Botswana. 2010 . (accessed July 8, 2011)

NACA. 2008. HIV Prevention in Botswana .

Spino, A. 2009. Secret Lovers Kill: A National Mass Media Campaign to Address Multiple and Concurrent Sexual Partnerships. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.

Spino, A. 2009. The Scrutinize Campaign: A Youth HIV Prevention Campaign Addressing Multiple and Concurrent Partnerships. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.

UNAIDS. 2008. Country Profiles: Botswana .

REFERENCES

Central Statistics Office (CSO), Republic of Botswana. 2009. Preliminary Results from Botswana HIV/AIDS Impact Survey III, Stats Brief. Gaborone: CSO.

Epstein, H. 2007. The Invisible Cure: Africa, the West, and the Fight against AIDS. New York: Farrar, Straus, and Giroux. Associated website .

Gregson, S., et al. 2002. Sexual Mixing Patterns and Sex- Differentials in Teenage Exposure to HIV Infection in Rural Zimbabwe. The Lancet 359(9321):1896–903.

Guwatudde, D., et al. 2009. Relatively Low HIV Infection Rates in Rural Uganda, but with High Potential for a Rise: A Cohort Study in Kayunga District, Uganda. PLoS ONE 4(1):e4145.

Halperin, D. T., and H. Epstein. 2007. Why is HIV Prevalence so Severe in Southern Africa? The Role of Multiple Concurrent Partnerships and Lack of Male Circumcision: Implications for AIDS Prevention. The Southern Africa Journal of HIV Medicine 26:19–25.

Mah, T. L., and D. T. Halperin. 2010. Concurrent Sexual Partnerships and HIV Epidemics in Africa: Evidence to Move Forward. AIDS and Behavior 14(1):11–6, discussion 34–7.

Morris, M., and M. Kretzschmar. 1997. Concurrent Partnerships and the Spread of HIV. AIDS 11:641–8.

Msuya, S., et al. 2006. HIV Among Pregnant Women in Moshi, Tanzania: The Role of Sexual Behavior, Male Partner Characteristics and Sexually Transmitted Infections. AIDS Research and Therapy 3(1):27.

National AIDS Coordinating Agency (NACA). 2007a. Mid-term Review of the Botswana National Strategic Framework for HIV and AIDS 2003–2009. Gaborone: NACA.

NACA. 2007b. National Operational Plan for Scaling Up HIV Prevention in Botswana: 2008–2010. Gaborone: NACA.

NACA. 2009a. National Campaign Plan, Multiple Concurrent Partnerships. Gaborone: NACA.

NACA. 2009b. Multiple Concurrent Partnerships Campaign: Monitoring, Research and Evaluation Plan. Gaborone: NACA.

Potts, M., et al. 2008. Reassessing HIV Prevention. Science 320:749–50.

Population Services International (PSI). 2010. MCP National Campaign Briefing. PowerPoint presentation. Gaborone: PSI.

Southern African Development Community (SADC). 2006. Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa Report. Gaborone: SADC. (PDF, 565 KB) (accessed July 8, 2011)

UNAIDS. 2008. Epidemiological Fact Sheet on HIV and AIDS, Botswana. Geneva: UNAIDS. (PDF, 737 KB) (accessed July 8, 2011).

ACKNOWLEDGMENTS

Special thanks to Joan LaRosa (USAID/Botswana); Toby Kasper, Cate O'Kane, and Iris Halldordottir (PSI/Botswana); Thatayaone Gabositwe (NACA/Botswana); and Timothy Mah (USAID/Washington, DC) for sharing their experiences and insights about designing, planning, implementing, and evaluating the campaign. Their detailed and knowledgeable comments on the case study were also greatly appreciated. Thanks also to the many partners who generously gave their time for the development of the case study: MOH, MLG, Academy for Educational Development, Pathfinder, ACHAP, Truemen, the Youth Health Organization, Tebelopele, Research Triangle Institute, National Alliance of State and Territorial AIDS Directors, Makgabaneng, Humana People to People, and Botswana Network of People with AIDS.

RECOMMENDED CITATION

Lillie, Tiffany. 2010. The O Icheke Campaign, Botswana: A National Behavior Change Communication Program to Reduce Multiple and Concurrent Partnerships. Case Study Series. Arlington, VA: USAID's AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.