The International AIDS Society (IAS) convenes, educates, and advocates for a world in which HIV no longer presents a threat to public health and individual well-being. As part of its convening efforts, the IAS hosts the world’s most prestigious HIV conferences: The International AIDS Conference, the IAS Conference on HIV Science, and the HIV Research for Prevention Conference. The three Conferences provide an opportunity to share lessons that galvanise the scientific response, build global solidarity and enhance human dignity for all those living with and affected by HIV. AIDS 2022 is the 24th edition of the International AIDS Conference and will take place from July 29, 2022 to August 2, 2022 in Montreal, Canada, and virtually.
Tackle (TA) is passionate about innovation with proven success, and as part of our efforts to contribute to driving evidence-based progress in the HIV response, we submitted an abstract to AIDS 2022 on a recently evaluated project. “Scaling HIV/SRHR education through football coaching programmes in Southern Africa” was a 2 1/2 year project made possible by generous funding from Comic Relief and implemented in select correctional facilities in Malawi, Zambia, and Zimbabwe in partnership with Voluntary Service Overseas (VSO) and with the collaboration of authorities from the relevant facilities.
Often isolated, disenfranchised, and marginalised, UNAIDS considers inmates and other incarcerated people as one of the five key population groups that are particularly vulnerable to HIV and frequently lack adequate access to services. In fact, according to various reports (including those from Human Rights Watch and UNODC), the prevalence of HIV in African correctional facilities has ranged from 6 to 50 times higher than outside them. The high rates of HIV and other communicable diseases in correctional facilities can be attributed to inadequate access to health services and also to the poor physical environment that includes poor diet, ventilation and sanitation, sexual violence, intravenous drug abuse, and severe overcrowding. The situation is particularly worrisome in the Southern African Development Community (SADC) region, host to some of the highest imprisonment rates and largest inmate populations in Africa. Unless this situation is addressed with targeted interventions, international targets around sexual health and HIV like “95-95-95” will not be met.
Conceived and implemented to respond to these harsh realities, the “Scaling HIV/SRHR education through football coaching programmes in Southern Africa” project aimed to increase inmates’ knowledge of sexual and reproductive health & rights (SRHR) to minimise the impact of HIV/AIDS while also improving HIV knowledge, transforming gender-based attitudes and providing access to services. This speaks to our organisational objective, that is, to inform, support, and challenge young Africans to make safer decisions (limiting the impact of HIV in their communities), as well as to empower disadvantaged young people and help create better futures for them and their communities.
The project was implemented across 14 correctional facilities in Malawi, Zambia, and Zimbabwe. The facilities included maximum facilities where inmates have sentences ranging from 5 years to life, medium/open facilities where sentences range from 2-5 years, remand facilities where people await trial, and mental health institutions for those diagnosed with mental illnesses. Some facilities were single-sex and others had both male and female inmates. The primary actors were inmates and officers who were trained to become sexual health educators who used football to integrate and disseminate sexual health messaging. Equipped with the necessary leadership skills and sexual health knowledge, the inmates were then able to facilitate weekly sessions targeting other inmates within the facilities. In addition to the 10-week block of sessions, tournaments were held where services like HIV testing and STI screening were provided.
- 126 inmates trained as peer football coaches
- Reached 2,920 male inmates with 1,047 football sessions
- 1,200 inmates tested for HIV; 15 new positive results, all of whom were linked to treatment
- Baseline and end-line surveys conducted to measure participant changes in HIV/STI knowledge, attitudes, and beliefs related to gender roles or sexual and gender-based violence (SGBV)
An external evaluation confirmed the Tackle ‘Football for Health’ approach had transformed the knowledge and attitudes of participants regarding HIV, SRHR, and gender equality.
- Effectiveness of the TA model: Nearly 100% in Zimbabwe, 98% in Zambia, and 99% in Malawi of respondents agreed the project empowered them to make informed decisions about sexual behaviour and relationships
- HIV and SRHR knowledge, attitudes & service uptake: 6% of the sampled inmates had accessed STI screening; An average of 22% improvement in HIV–related knowledge, attitudes, and service–seeking behaviour; 79.7% shared their newly acquired information with other individuals; 54.3% sought HIV and/or SRHR services, and 40% self–reported that they stopped/reduced risky behaviours that exposed them to HIV and STIs infection
- Perceptions on gender roles and safe sex: 90% and 94% disagreed with notions that women should tolerate SGBV; 22-29% increase in respondents who did not agree that a female partner is responsible for ensuring protected sex; 95.2% agreed condom use should be a joint decision
In Zambia, there was an increase in positive attitudes of male inmates’ towards women. 79% correctly answered whether a girl should be able to ask her partner to wear a condom, an increase from 68% at baseline. The response to ‘should a girl be able to refuse unwanted sex from her husband or boyfriend’ also increased to 79% from 71%. Given that a high proportion of the maximum-security inmates are alleged to have committed sexual offences, this is a positive change.
An ex-inmate said, “I never respected women, but relationship sessions in class and at the pitch changed how I looked at things and when I was released people noticed that change… I had the confidence to challenge men that never valued women’s point of view.”
In Zimbabwe, it was a similar situation with 91% correctly identifying that having sex with many women is not a sign of manhood, an increase from 84% at baseline. In Malawi, 71% of inmates correctly answered at endline, compared to 52% at baseline. While these increases are a great start, more needs to be addressed around male and societal attitudes towards women in areas around gender norms and relationships.
- Trained inmate coaches were reported to be technically competent enough to drive the programme without the support of VSO and TA personnel
- Trained inmates were found to be sharing the information accessed and knowledge gained through the project with fellow inmates, thereby building a movement that could continue to positively influence successive generations of inmates
- Prison and Correctional officers (PCOs) had mastered the ‘Football for Health’ approach and enjoyed using it not just for SRHR purposes but for the rehabilitation programs as well
- Released inmates were reported to be championing ‘Football for Health’ ideas in their communities, and they were doing this independently of the main project
Once released some inmates have reached out to Tackle staff seeking ways to stay involved in the programme; such eagerness provides an exciting opportunity for us to explore using football and our drills as an effective community reintegration mechanism. This also speaks to the heart of the TA model’s sustainability as – by design – those trained should be able to take the skills acquired to continue conducting sessions after the completion of our projects.
- Real impact: PCOs in all three countries reported the project reduced recidivism rates among participants. Additionally, conducting community outreaches reduced stigma and discrimination against former inmates.
“SRHR awareness campaigns have been going on in prisons, but they did not yield the kinds of results as what we are seeing now… this is because of the creative approach that this project uses.” – PCO, Malawi
- Unintended impact: PCOs unanimously reported the project improved inmates’ discipline, thereby raising chances of sentences being reduced. This created a need for retraining new coaches as some of the older ones were released early. In the future, it would be great to also focus on the mental health and wellbeing outcomes that can be achieved by such projects alongside those of HIV or SRHR.
“The programme also gives me a sense of purpose. I now have a responsibility. I train my team every morning from 8-10 and then again in the afternoon from 2-4. This keeps my days busy and allows me to concentrate on something meaningful.” – Inmate Coach, Zambia
Numerous lessons were learnt during implementation, the most important of which is that inmate-led sports-based interventions are a sustainable and effective way to engage with and transform the attitudes of a highly marginalised and disenfranchised group, as well as their community. Given the lack of fun, informative, education methods in correctional facilities or closed settings, football is an effective vehicle and should be considered in future project design around SRHR and HIV education for inmates and others living in closed settings. However, we acknowledge that football may not be the sport of choice for all, thus it may be necessary to diversify beyond football while still maintaining and replicating the underlying principles of the Tackle ‘Football for Health’ approach.
Going forward, lessons from the “Scaling HIV/SRHR education through football coaching programmes in Southern Africa” project have enabled TA secure funding from another partner to expand programming to a different correctional facility in Zambia. TA has also applied for similar funding with SANOP in Malawi that will enable the continuation and scaling up of the work. If successful, it will be an opportunity for the VSO volunteers that TA already trained to continue working alongside us in the correctional facilities. Although there is currently no funding secured for this particular work, we are also excited to learn how the TA model could be used to support the reintegration of ex-inmates into their communities.
Finally, the project also revealed the need for continued testing of HIV and STIs within correctional facilities. Even though inmates are tested on arrival and again six months later, it is evident from this project that people are not fully protected from contracting HIV while incarcerated. Therefore, there is a need for NGOs and development organisations to use evidence to inform and strengthen advocacy efforts to achieve policy change. To better support inmates and their sexual health, an acknowledgement is required at the government level that sexual activity happens in correctional facilities. This acknowledgement will allow for the distribution of condoms and other sexual health commodities that can support inmates in realising their rights and taking control of their sexual health.
For access to resources and information about AIDS 2022, please visit https://www.aids2022.org/
For additional information about our funder, Comic Relief, please visit www.comicrelief.com
For additional information about our partner, VSO, please visit www.vsointernational.org