Bumb’INGOMSO – isiXhosa for ‘mould the future’ – is a multi-faceted HIV-prevention project that combines behavioural, biomedical, social and economic interventions to inspire, support and motivate girls and young women to reduce high-risk behaviour and make healthy life choices. Its design reflects international evidence that multi-faceted combination prevention, sustained at sufficient scale and intensity, can significantly reduce the incidence of HIVBekker L-G, Beyrer C, Quinn T. 2012. Behavioral and Biomedical Combination Strategies for HIV Prevention. Cold Spring Harb Perspect Med. 2012 Aug; 2(8): a007435. doi: 10.1101/cshperspect.a007435 PMCID: PMC3405825.
Launched in 2016, the project addresses the individual, interpersonal and structural factors that drive the vulnerability of girls and young women in a specific locality – the Buffalo City Metropolitan Municipality – through programmes that include leadership development, tackling gender-based violence, improving the delivery of youth-friendly health services, and connecting young people to economic opportunities. Through these interventions, it aims to build self-efficacy and a sense of real and imminent possibility that shifts the social and structural dynamics shaping young women’s lives.
Bumb’INGOMSO is a development project of the National Department of Health (DoH), and is co-financed by the Federal Republic of Germany through KfW and DGMT, which is also the executing agent. It is currently being implemented across 18 wards in the Buffalo City area in partnership with Small Projects Foundation, Beyond Zero, Masimanyane Women’s Support Centre, Harambee Youth Employment Accelerator, DreamWorker, Masibumbane and Rural Education Access Programme.
By 2021, Bumb’INGOMSO aims to have helped reduce the incidence of new HIV infections in 15-29-year-old women within the Buffalo City Metropolitan Municipality by a third.
First-year students from Walter Sisulu University pictured here attending the Bumb’INGOMSO Opportunity Hub, where they completed online Microsoft Learning Modules. Bumb’INGOMSO’s Opportunity Hub runs in collaboration with REAP to facilitate job-readiness training, including computer skills development – particularly important for youth from rural areas with little to no experience using computers.
South Africa has the largest HIV epidemic in the world with just over 7.5 million South Africans living with HIV, or 13% of the general population; for adults aged 15-49, the prevalence rate is a staggering 19%Statistics South Africa. 2018. Mid-year population estimates 2018. Available here .
Almost 90% of the lifetime probability of infection with HIV is crammed into the decade of life immediately after leaving school. The prevalence rate rises from 2.7% among children aged 5-14 years to about a quarter of all adults aged 25-29 years of ageShisana, O., Rehle, T., Simbayi, L.C., Zuma, K., Jooste, S., Zungu, N., Labadarios, D., Onoya, D. et al. 2014. South African National HIV Prevalence, Incidence and Behaviour Survey, 2012. Cape Town, HSRC Press.. Women bear the brunt of infection in young adulthood, accounting for almost 80% of infections in 15-24-year-olds. This is largely as a result of sexual relationships with older men. But, as young women mature, HIV infection spreads to their male peers. Recent South African HIV prevalence data for males showed that the prevalence for 25-29-year-old male is 12.4%, 30-34 years is 18.4% and 34-39 years is 23.7%, which is substantially highHuman Sciences Research Council (HSRC). 2018. The Fifth South African National HIV Prevalence, Incidence and Communication Survey, 2017: HIV Impact Assessment Summary Report. Cape Town: HSRC Press. When those men have sex with younger women, the cycle of infection is repeated (see diagram below)UNAids. 2017. A snapshot of men and HIV in South Africa..
While it is encouraging to note a decline in prevalence among younger people aged 15-24 years, from 7.3% in 2002 to 4.6% in 2017Statistics South Africa. 2017. Mid-year population estimates 2017. – which implies a significant drop in incidence among 15-19-year-old women, and suggests that behaviour-change programmes have been effective in reducing risk tolerance among adolescents – the incidence among 15-24-year-old women remains very high at 2.5% per year. This spike of infection in early adulthood is what drives the epidemic. Curbing new infections in this age group could therefore significantly reduce the overall prevalence of HIV in South Africa.
School-leaving – either through dropout or school completion – is a particularly vulnerable time for adolescent girls, and is associated with marked changes in sexual behaviourHargreaves, J., Bonell, C., Boler, T., Boccia, D., Birdthistle, I., Fletcher, A., Pronyk, P., Glynn, J. 2008. Systematic review exploring time trends in association between educational attainment and the risk of HIV infection in southern Africa, AIDS 22:403-414.. The persistence of high incidence among young women in the five years post-school suggests that this age group is not as amenable to behaviour change programmes. This is most likely because this is a period when:
Young people in South Africa also find themselves living in a highly polarised country where, for the majority, “day-to-day choice and opportunity are severely constrained, and prospects of real improvement are poor”Harrison, D., Richter, L. & Desmond, C. 2007. Changing Perceptions of Opportunities: Hope for Young People in High HIV-Risk Environments. Available here. Feeling trapped at the bottom of the pile can predispose young people to risky behaviours, such as inconsistent condom use and relationships with older men.
There is, however, opportunity in the youthfulness of the South African population. In the Eastern Cape, the median age is 23Statistics South Africa. 2012. Results of Census 2011., which creates the prospect for a rapid reduction in the HIV epidemic if the province’s current generation of children and teenagers can grow up with far lower rates of infection. While the Eastern Cape has a lower rate of HIV infection than five other provinces – largely because a higher proportion of the province is rural, which is generally associated with lower rates of infection – the rate of infection, which had remained stable between 2005 and 2008, has shown a sharp increase over the past few years, from 9% in 2008 to 11.6% in 2012. This implies that the epidemic has crossed a threshold, where ‘hot spots’ have begun to coalesce, driving up the rate of new infections. Even with effective programmes, it will be difficult to show a reversal in this trend; however, a slowing of the rate of increase, with the potential for the epidemic to plateau at a lower point than would have occurred without intervention, is possible.
It is within this context that Bumb’INGOMSO aims is to reduce HIV infection and early teen pregnancies in among young women 18 years and younger by deferring sexual debut, reducing the frequency of partner change and concurrency of partners, and increasing the consistency of condom use. In terms of connecting young people to opportunity, the high prevalence of HIV imposes additional psychological and physical burdens on young people, making job-seeking and job-keeping even tougher. Reducing the incidence of HIV would significantly help to improve the work prospects of women aged between 20 and 29 years old; at the same time, the prospect of employment can serve as a protective factor against risky behaviour that could lead to infection with HIV.
Buffalo City Metro Municipality (BCMM) is located on the east coast of the Eastern Cape province and has a predominantly young population: 20-29-year-old adults constitute the largest age group, followed by 15-19 year old adolescents. Overall, the bulk of BCMM’s population lives in urban areas, with over 50% of inhabitants residing in East London and Mdantsane; 12%, or 90 000 people, live in one of the municipality’s 154 informal settlements – important to consider given that living in informal urban settlements can be a strong predictor of infection with HIV. According to the Eastern Cape Aids Council, Buffalo City Metro has the third highest HIV prevalence in the province, with almost 12 000 young people living with HIV. Forty-eight percent (48%) of deaths between 2008-2013 in women aged 15-24 were linked to HIV and TB.
Bumb’INGOMSO uses an innovative approach to HIV prevention that combines traditional HIV-prevention mechanisms, such as behaviour change communication and biomedical interventions, with interventions that tackle the underlying individual, social and structural drivers of the epidemic in particularly vulnerable populations, like those with limited access to economic opportunity and high levels of exposure to gender-based violence.
To support and empower girls and young women to navigate factors that may otherwise make them more tolerant of risk, Bumb’INGOMSO works with partners to provide the following interventions:
For behaviour change to happen, Bumb’INGOMSO believes that young people must first be able to understand themselves and have a sense of community, connectedness and the ability to make informed choices in their lives. To this end, the project has established an aspirational leadership network – the Bumb’INGOMSO Leadership Network (BLN) – the Bumb’INGOMSO Leadership Network (BLN) –that builds a sense of ownership and connects young women to opportunities. The BLN encourages and supports young women to lead change in their homes, schools and communities through hands-on training programmes, mentorship and ongoing support.
In schools, Bumb’INGOMSO drives a motivational peer-driven programme, called BI Clubs, focussed on personal development opportunities and the promotion of healthy sexuality. The programme is implemented through a combination of interactive workshop-based and recreational activities. Both girls and boys are included in these activities to ensure that gender disparities are addressed in the process.
For young people outside of school, a sense of belonging is promoted through interpersonal clubs and social media messaging linked to the Bumb’INGOMSO Opportunity Hub (see Strategy 4 below for more about the Hub). The project also offers a call centre that can be accessed from any mobile phone network at no cost, and provides referrals to relevant services for young women who call in.
To mobilise and engage the broader community around issues that affect the wellbeing of young people, and to further stimulate a sense of identity and self-efficacy among young women, Bumb’INGOMSO also publishes a popular magazine, YAKHA. The magazine is produced quarterly with a print run of 40 000 copies, and an estimated readership of 160 000, who access the magazine for free via Bumb’INGOMSO’s implementing partners. YAKHA is produced by young people living in the Buffalo City Metropolitan Municipality – which includes East London, King Williamstown, Bhisho and the surrounding areas – who are supported and mentored by a seasoned editorial team.
Effective health services enable young people to make informed choices about their bodies and sexual health. Bumb’INGOMSO aims to increase metro-wide access to youth-friendly care, to get all 77 public health facilities in Buffalo City capacitated to strengthen youth-friendly services. This includes:
In addition to training nurses to be sensitive to the circumstances that impact young people’s health, Bumb’INGOMSO also regularly embarks on outreach activities in communities and learning institutions to bring basic health services to young people.
Bumb’INGOMSO also collaborates with the DoH to implement a data capturing system designed to effectively capture information on how young people access and move through the public healthcare system. In time, the project seeks to help strengthen public health services provided to hard-to-reach high-risk communities such as sex workers and incarcerated offenders.
Given young women’s greater physical as well as social vulnerability to infection with HIV, Bumb’INGOMSO seeks to mobilise and engage communities to be actively involved in the prevention of gender-based violence (GBV). Reducing domestic violence is at the heart of tackling gender-based violence because much of GBV is perpetrated in the home, and because GBV is perpetuated from one generation to the next through behaviours learnt in the homeWessels, I., Mikton, C., Ward, C.L., Kilbane, T., Alves, R., Campello, G., Dubowitz, H., Hutchings, J., Jones, L., Lynch, M., Madrid, B. 2013. Preventing violence: Evaluating outcomes of parenting programmes. Geneva, Switzerland, World Health Organization..
Bumb’INGOMSO’s work within communities provides capacity building and leadership development for men and women, in the effort to create spaces where both men and women can address the norms that gender-based violence. Domestic violence prevention, detection and referral information is also integrated into Bumb’INGOMSO’s campaign communication and training/workshop curriculum.
Furthermore, the project is working to strengthen the justice system as one of the main weaknesses of the institutional response to gender-based violence is the lack of connection between different role players in government departments, civil society, and academic institutions. This results in ineffective case management and failure to prioritise gender-based violence in budgets and business plans. In addition to developing effective referral mechanisms across institutions, and building a leadership network of professionals across agencies that provide services and support, Bumb’INGOMSO is working on an immediate package of support for victims of violence, including practical aspects like cellphone airtime and travel vouchers, and is collaborating with the Department of Social Development to register and upgrade emergency shelters.
Bumb’INGOMSO regularly hosts campus activations at tertiary institutions across Buffalo City, like this one at Buffalo City College.
In the Eastern Cape, information and mobility barriers seriously impede the life choices of young people, even those who are employable – making them more tolerant of hazards such as HIV. Bumb’INGOMSO empowers young people by improving their access to skills training and information about available opportunities through its Opportunity Hub, which serves to:
Young people will access vocational skills training and work readiness programmes that prepare them for the world of work.
By the end of 2018, Bumb’INGOMSO had made the following gains:
To further increase its visibility, Bumb’INGOMSO launched a billboard campaign in 2017. The Bumb’INGOMSO call centre has also made significant inroads, interacting with 2 300 callers and responding to 22 088 messages since it was established in 2018. And to build on the popularity of YAKHA magazine, which has had eight issues published to date, a lunchtime radio slot was secured on Mdantsane FM in 2018 that focused on the campaign’s interventions, with features still broadcast on Wild Coast FM, Izwi Lethemba and Tru FM.
Given the high number of people who do not go on to complete their schooling in the municipality – only 31% of residents 20 years and over have a matricBuffalo City Metropolitan Municipality. Integrated Development Plan Review 2018/2019. Access here – Bumb’IMGOMSO will launch a matric rewrite support programme as part of the Opportunity Hub in the second quarter of 2019 as part of its efforts to link youth to further education and employment opportunities.
Finally, while girls and young women are at the heart of the Bumb’INGOMSO project, their high rates of infection are largely driven by relationships with older men. To decrease transmission rates of HIV to young women, the project is aiming to increase its coverage of men between 25 to 39 years of age in the Buffalo City Metro Municipality from 4 000 to 20 000. It plans to do so primarily through behaviour change communication to stimulate positive health-seeking behaviour and healthier attitudes and sexual practices (e.g. reduction in the frequency of partner number and change, and consistent condom use).
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