This report comprehensively summarizes the FHI/AIDSCAP program in Zimbabwe (1992-1997). The report includes a country context description, accomplishments, constraints, and outcomes of the program, and a series of lessons learned and recommendations.

Table of Contents

I.Executive Summary

II.Country Program Description

A.Introduction

B.Country Context

C.Accomplishments and Outcomes
  -Page 1
  -Page 2 (See Below)
  -Page 3
  -Page 4

III.Lessons Learned & Recommendations

IV.Subproject Highlights
  -Page A
  -Page B
  -Page C

V.Non-Subproject Highlights

VI.Attachments

 

II. Country Program Description (continued)

d. Improvement of STI treatment seeking behavior

A population-based study in the rural Mwanza region of Tanzania demonstrated that improved STI treatment at a primary health care level reduced the incidence of HIV by 42 percent This study emphasized the importance of early as well as effective STI treatment. While the World Bank/ODA funded STIPCP has worked with the MOH to improve STI diagnosis and treatment services in Zimbabwe, not all GOZ health facilities have trained personnel, and drugs are not always available at the ones that do owing to transport problems (between 62 and 91 percent of first line drugs were available during a recent situational analysis). This, however, is an improved state of affairs and one that is likely to be communicated informally within communities. Improved STI treatment at GOZ health facilities provides an accessible and affordable option for STI treatment, especially for those whose employers charge or punish them when they attend company/military base facilities for STI treatment.

The AIDSCAP Country Office promoted STI treatment seeking behaviors by working with IAs to:

• Include signs and symptoms of STIs in trainer's and peer education curricula;

• Train peer trainers and peer educators so that they understand not only signs and symptoms of STIs but the importance of early treatment;

• Liaise directly with clinic staff in their communities.

Information collected from NRZ, ZNA, AFZ, and Triangle suggests that people are learning more about STIs and may be seeking treatment earlier. For example, the number of cases of STIs treated at the 16 NRZ clinics increased over the life of the project. For the first eight months (10/95-5/96) between 50 and 100 cases were treated per month. This number increased to between 100 and 150 during the last ten months (with over 150 in January 1997). Because the NRZ fines employees for being treated for an STI, it is difficult to determine what percentage of the population infected with STIs actually seeks treatment at NRZ clinics. One positive interpretation of the increase in attendance could be that there really is less stigma attached to having an STI now, so more employees are seeking treatment at NRZ clinics.

Both the Army and Air force continue to regard STI infections as a punishable offense which does not encourage early treatment seeking behaviors. The ZNA reported a "downward trend in STIs which implies some form of behavior change and/or increased use of condoms. Even though people still seek treatment elsewhere those who report to camp hospitals are doing so as soon as they observe symptoms." While the AFZ reports that the number of cases of STIs treated at camp health facilities is going down, they too suggest that the trend must be interpreted with caution because many air force personnel seek treatment for STIs off base.

Additionally, survey data from the Triangle project which houses STI clinics on the estate showed that 44 percent of adult female workers and 46 percent of CSWs who reported to a health facility with an STI were advised on condom use and partner notification (PI 7). From January 1996 through April 1997, 3,984 cases of STIs (an average of 249/month) were treated at the Colin Hospital which serves Triangle employees.

e. Condom promotion and accessibility

The AIDSCAP Country Office played a role in establishing linkages among NGO grantees and GOZ and/or private sector suppliers of condoms and STI services. They facilitated access to condoms for IAs through coordinated efforts with the Condom Manager for the STIPCP, who is based at the NACP, and the ZNFPC who are responsible for clearing, storing and distributing ODA-funded condoms.

Nevertheless, condom supplies were irregular and sometimes insufficient during the first several months of AIDSCAP country program implementation This problem was addressed as follows during the program review in March 1996.

Since there seemed to be few problems with distribution up to the provincial level, it was suggested that AIDSCAP IAs take responsibility for distribution from the provincial store onwards, taking care to forecast future use accurately to avoid local stockouts. This strategy seemed to resolve the problem as condom distribution problems were not expressed during the quarterly meeting in November 1996 and only surfaced in February 1997. One organization, which had recently lost a project manager, was having difficulties that appeared to be more related to the change in management than the system.

An end of project knowledge, attitudes, beliefs and practices (KABP) survey for CFU conducted in March 1997 reported a drop in reported condom availability on the peripheral level from 80.5 percent in 1995 to 70.2 percent in 1997. Although the results seemed to be in direct opposition to reports from the CFU project staff and process indicator forms (PIFs) which showed a great increase in condoms distributed in 1997 compared with 1995, the results could be explained as a reflection in difference in survey populations and sites. The sample size in 1997 was increased and the survey was conducted on a number of farms new to the project, some of which were just setting up condom distribution systems.

Condom distribution increased over the life of the project, indicating either a wider acceptance or much more frequent use by the same population. The following chart shows targets and actual numbers of condoms distributed per year by each IA.

Table 1: Condom Distribution Compared to Target for each Implementing Agency

NRZ project personnel attribute low condom usage in the early stages of the project to a strong initial emphasis on moral values, i.e. abstaining when not married and faithfulness to one's partner. Additionally, the distribution system was not user-friendly and was subsequently changed. Condom outlets are now more anonymous with dispensers located in toilets and around canteens.

Triangle experienced condom distribution problems in 1996 and early 1997 which were later resolved. Additionally, a local research company also distributed condoms during several months of AIDSCAP project implementation indicating that condom use was more than likely much higher than was reported on PIFs.

While the armed forces do not release statistics about their service men believed to compromise national security, the AFZ did report that condom demand increased from about 2,000 to 5,000 condoms per month by the end of the project, with higher demands during weekends and at month end. While this increase is likely linked to the peer education program, it is also likely to be attributed to the increase in the number and variety of distribution points. Not only did all peer educators supply (free) condoms, but they were available for distribution in all toilets in the squadrons, messes, and canteen counters. There was also a condom contact person in every section.

AIDSCAP projects promoted condom use through peer educators, materials and media. Peer educators were given basic skills through formal classes which enhanced these skills as they took their activities to their peers. They often had strong cultural and economic barriers to work through, however. Sometimes they were successful and sometimes they were not and had to think of another approach, another, and yet another....

As the AIDSCAP project came to a close, the condom social marketing project was being revitalized by Population Services International (PSI) and President Mugabe had dedicated Z$ 43 million to the import of female condoms for distribution. The AIDSCAP County Office facilitated discussions between PSI and IAs as potential selling/distribution points for the PROTECTOR condom.

f. Behavior research

As part of an eight country study, AIDSCAP conducted an exercise designed to listen and learn from the people who implemented AIDSCAP-supported projects throughout the world. Zimbabwe was one of the study countries where in-depth interviews and FGDs were conducted with project field workers and peer educators. The final product of this study was a report illustrating some of the Experiences from the Field of implementers in the eight study countries. Many of the quotes in this EOP report were taken from transcripts of those interviews and FGDs.

One or two data points were established with KABP surveys and qualitative research on all the AIDSCAP target populations. Two data points were established for commercial farm workers, transport workers, commercial sex workers and youth. Second data points will be developed for the other target groups under the follow-on cooperative agreement. The outcome data resulting from this research is presented in the following section of this report.

Family Health International is working with local researchers on a USAID-funded research effort under the Women's Study Project (WSP). Women's organizations, reproductive health providers, policy makers and researchers are collaborating in an effort to introduce a woman's perspective to gender-sensitive policies and services in family planning. They are looking at family planning as it impacts on the quality of life of women (based on their cultural definition). In Zimbabwe, this research focuses on the role of women in the development process. As integration of sexual and reproductive health with HIV/AIDS/STI prevention and control services is critical to the next phase of the USAID ATSP, these research findings are expected to assist with future project design.

There has been a great deal of research conducted in Zimbabwe related to reproductive health, including HIV/AIDS/STIs and it was important to identify the gaps and follow up. FHI/AIDSCAP commissioned the Southern Africa AIDS Information and Dissemination Service (SAfAIDS) to undertake a literature search and review of HIV/AIDS related research and studies conducted in Zimbabwe between 1987 and 1996. For this exercise, 125 studies and research papers were reviewed in 13 different topic areas. The result was a comprehensive report indicating what has already been accomplished. The review contains an assessment of what research has been done, identifies research gaps, gives an analysis of conclusions and makes recommendations for future use and orientation of research in selected topic areas. The thirteen topic areas reviewed were: adolescents and youth, attitudes and behavior change, condom use and acceptance, coping behaviors of persons living with AIDS, diagnosis and management of HIV, discrimination, female condoms, HIV prevention and control, information and communication, integration of family planning into HIV/AIDS, sexual behavior, STIs, and women.

Key Findings related to behavior from Literature Search and Analysis on HIV/AIDS in Zimbabwe are presented below:

Adolescents and Youth

Seven studies were analyzed which appear to confirm that the level of knowledge concerning HIV/AIDS among this population in both urban and rural areas has improved considerably. Youth engage in sexual activities at an early age and most of their sexual behavior responses are rooted in cultural sexual instruction. The common conclusion of the majority of studies is that adolescents have special educational needs. Adults view adolescent sexuality as a problem rather than a normal developmental process.

The studies reveal that the needs for reproductive health information of adolescents, including HIV/AIDS, should be integrated within schools. The specific needs of adolescents relating to their general development and socialization are not yet fully understood by parents and teachers who still struggle with issues around sex, sexuality and relationships. The major research gap is the lack of information and research concerning out-of-school youth.

Attitudes and Behavior Change

Results from 32 KABP studies showed a high level of general knowledge on HIV/AIDS. There was generally a negative relationship between age and accurate information on AIDS; as age increased, knowledge decreased. However, the opposite was true for behavior change as more young people were likely to engage in risk behaviors, despite their high levels of knowledge. Attitudes seemed to be a function of the cultural construction of sexuality which discouraged women from making sexual decisions and encouraged men to engage in multiple sexual relationships and generally to be sexually adventurous at an early age.

The studies also conclude that transmission of HIV results from engaging in high risk behavior rather than simple membership of the so-called high risk groups. Results from these high risk groups did not show a significant difference compared to those from general populations. This pointed to a need for new generations of intervention strategies that combine individual skills development with community-based norm change.

SafAIDS would like to see more research linked to programs, a move away from convenience sampling to more representative sampling and more research done on the possible prerequisites for behavior change. Additionally, study designs should allow for more in-depth analysis of behavior and attitudes than is represented in this literature search.

Sexual Behavior

While the main focus of these studies was on sexual behavior, there was a strong bias toward AIDS awareness and KABP survey methodology. The main conclusions drawn from these studies is that prevention messages should target risk behaviors and move away from the "risk population group" paradigm, family life education should begin at an early age and should incorporate gender equality issues.

Vaginal substances that allow for dry sexual practices are used amongst women of all social and economic strata; popularity of using vaginal substances is based on male and female perceptions of sexual preference. Men have significantly more sexual freedom than women, especially men who are away from their wives, and engage in casual sex or sex with changing partners. Men do report, however, that they have changed their sexual practices as a response to the AIDS epidemic.

Sampling procedures need to be improved as the majority of the studies used urban-based males and relied heavily on volunteers as study subjects, limiting the representativeness of the sample. Survey methodology was primarily used which relies heavily on self-reported behaviors which do not necessarily correspond with actual behaviors.

Women

Seven studies were carried out between 1992 and 1996 with study populations varying from 30 to 1,800. The research showed a significant power imbalance between men and women which places women at considerable risk as they have no social or cultural backing to prevent their husbands from having sexual relations outside their relationship. The patriarchal tradition and prevailing social and economic development have created an environment favorable to the spread of HIV.

More comprehensive research should be conducted especially related to norms surrounding sexuality, motherhood, and marriage; health seeking behavior of women with repeat STIs and men's attitudes, perception and behavior needs to encourage equal participation from men in AIDS prevention efforts.

g. Summary PIF table for aggregate country program

Monthly collection of process data (with the exception of the Commercial Farmers Union who submit data on a quarterly basis) proved to be one of the most valuable methods of project monitoring. With behavior change interventions, particularly sexual behavior change, process evaluation is the strongest measurement of project progress. One constraint to data collection was with field staff who were collecting data, but did not always understand the relevance of the data to project planning, implementation, and evaluation. Some also found the PIF difficult to understand and could not associate the information on the form with the activities on which they were reporting. Some project managers reported having problems deciding under which headings activities should be placed and how to ensure that persons educated were not counted more than once. Training was provided to project staff throughout project implementation but with the large number of peer educators reporting and staff turnover, it may not have been enough.

Zimbabwe Process Indicator Form

 

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