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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 II.Country Program Description C.Accomplishments and Outcomes III.Lessons Learned & Recommendations IV.Subproject Highlights VI.Attachments
II. Country Program Description (continued) 3. Project Outcomes a. Biologic/Impact Data (HIV/STI Seroprevalence) Sentinel surveillance for HIV is conducted regularly for antenatal women, commercial sex workers and STI patients in Zimbabwe. The most recent US Bureau of the Census Report (January 1997) shows seroprevalence rates for urban pregnant women at 32% (Harare, 1995) and rural pregnant women at 16% (Manicaland, 1993). Seroprevalence among sex workers in Harare is reported at 86% (1994-95) and STI prevalence among STI patients in Murewa District is 46% (1991-93). The NACP/MOHCW puts out a quarterly surveillance report on HIV/STIs and AIDS. The latest quarterly dated July to September 1996 shows a cumulative number of AIDS cases of 61,037 since 1987. The same document predicted that, with the rate of underreporting, more than 200,000 cases of AIDS were projected to have occurred by the end of 1996. A situation analysis funded by USAID and carried out by FHI/AIDSCAP at the beginning of 1996, however, pointed out that most AIDS deaths were based on HIV tests, rather than the clinical case definition together with the test dependent definition, and that health workers need to be trained in filling out death certificates to properly capture AIDS or AIDS-related deaths to avoid underreporting However, underreporting can be attributed to risk of loss of benefits of life insurance as well as to social stigma. The team also determined that there was limited funding for surveillance activities, hence inadequate personnel to direct data collection or processing at the government administrative level. The GOZ estimates that more than one million people are infected and that the HIV seroprevalence is greater than 30 percent in urban areas and as high as 15 percent in some rural areas. Sexually transmitted diseases have been shown to facilitate the transmission of HIV/AIDS especially where genital ulcers are present, hence, proper diagnosis and treatment of STIs contribute to the reduction in HIV infection. Studies conducted in Zimbabwe have shown that 60% of HIV-positive patients have STIs. The following table shows that the highest percentage of STI episodes are reported as 'Other.' Urethral discharge contributes 25.9% of total episodes, while genital ulcers which are crucial in transmitting HIV, contribute 24.6% of total episodes reported. Table 2: 1996 National Statistics on STIs
Source: NACP/Ministry of Health & Child Welfare. Annual Report 1996. Table 3: National STI Trends by Year
Source: NACP/Ministry of Health & Child Welfare. Annual Report 1996. Zimbabwe witnessed a decline in STI episodes in 1996. This could be attributed to the support given to the Government of Zimbabwe by the World Bank which provided STI drugs and training of staff. On the other hand, anecdotal evidence suggests that due to the fear of contracting HIV, people are seeking treatment early and thus not passing on infections. b. Outcome Data Background During the startup project implementation period outcome data were collected on each target population. Both quantitative (KABP surveys) and qualitative research (FGDs, key informant interviews or in-depth interviews) were carried out by several different evaluation research organizations. The University of Zimbabwe, Department of Community Medicine collected data on commercial farm workers and youth (Commercial Farmers Union) in July 1995; transport workers and high-risk partners (NECTOI) at the same time, and the military (Zimbabwe National Army and Air Force of Zimbabwe) in September/October 1995. Dexter Enterprises conducted evaluation research on male and female railway workers (National Railways of Zimbabwe) in July/August 1996, male and female sugar plantation workers (Triangle Ltd.) and CSWs living within the Triangle sugar estate at the same time. Hence, the first data point was established within a year of the sign-off date of the subagreement with participating implementing agencies and, given the length of time required for significant behavior change, can be considered an accurate representation of the knowledge, attitudes and behavior levels of the target populations at the beginning of the AIDSCAP interventions, taking into account interventions external to AIDSCAP as well as the preceding project interventions during the period of AIDSTECH (1987 to 1992). A second data point on commercial farm workers, youth, transport workers and CSWs was established two years later (April/May 1997) by Troparg Consultant Services and provides comparative data on those populations, albeit different sampling methodologies and data analysis were used. PSI supported a local agency to collect general population behavioral data in a countrywide KABP survey of 1,987 male and female respondents in urban areas in March 1997. Table 4: Evaluation Research Conducted under FHI/AIDSCAP/Zimbabwe
Since there is only one data point for railway workers, sugar plantation workers, the Army and Air Force, it is important to note that results from the "baseline" surveys will be available for comparison in future surveys. In addition, the surveys were used to get an accurate picture of the situation at the time and were used by program managers to refine their efforts; for example, knowledge levels were found to be fairly high, indicating that efforts should focus more on behavior change rather than simple dissemination of knowledge. The research was truly program-based and was immediately used to modify interventions. Disseminating the results of these surveys to the target populations would in itself be a valuable intervention, highlighting the gap between knowledge levels and behavior change. The data raise many questions and point to directions for future research, particularly the need for ethnographic studies to clarify reasons for continued high-risk behavior and to develop strategies for promoting behavior change. Overview Two data points exist for only transport workers, CSWs, commercial farm workers and youth (from two subprojects: CFU and NECTOI), however, it is not possible to compare results for the other target groups. Hence, for each target group, data will be presented either as a single indicator or, when available, the proportion change. When compared with the 1997 data, some of the 1995 data looked somewhat questionable. It was then reanalyzed, and these are the results presented in the report. Evaluation research showed high knowledge levels at baseline with slight increases at the second data point, with the exception of CSWs along NECTOI truck routes. However, this decrease in knowledge by only 1.9% is not significant. Respondents underestimated their chances of getting infected with HIV. Condom use levels increased in all groups except CSWs along NECTOI truck routes which went from 82.2% to 72.9%. Qualitative research highlighted a number of barriers to condom use, such as beliefs that condoms are painful and cause AIDS; and use of a condom with a regular partner indicates a lack of trust. CSWs said that financial issues were a major determinant of the number of sexual partners and whether or not condoms were used. Condom use data for youth was not comparable between the two data points as in 1995 they were asked to report on condom use in last sexual encounter as opposed to last sexual encounter of risk. Nonetheless, reported condom use in 1995 was surprisingly high at 52.7% for males and 62.5% for females. There was a correspondingly high reported access to condoms at 84.5% for males and 71.3% for females. This dropped to 57.1% for males and 40.8% for females in 1997 with a corresponding drop in condom use (in last sexual encounter of risk) to 20.8% for male youth and 7.6% for female youth. Knowledge of HIV Prevention Methods and Sources of Information The survey of the general population carried out for PSI in March 1997 showed 44% of both males and females were able to cite at least two methods of prevention and 57% were able to acquire a condom. Of those with a casual partner, 67% used a condom, however the report does not provide the denominator for this variable, nor is it disaggregated by gender. The reason given by this group for nonuse of a condom with a casual partner was unavailability of a condom. With the exception of NRZ and Triangle populations (NRZ 28-31% and Triangle 5-7%), knowledge levels of two prevention methods against HIV/AIDS were generally high; 87% and above. The population surveyed at Triangle could cite condom use as one method of prevention, but were not aware of other methods. Among commercial farmers, knowledge levels about HIV/AIDS (as measured by the proportion of the population able to cite two acceptable ways of protection against HIV) remained above 88% for adults (both male and female) and above 89% for youth, hence a reflection that AIDS prevention messages continue to be successfully disseminated. The target population for NECTOI was truck drivers and their assistants and commercial sex workers. Knowledge levels for drivers increased from 88% to 94%, and for sex workers it showed a minor trend downwards, from 84.2% to 82.3%. For the target populations with a single data point, knowledge levels were generally high (Zimbabwe National Army - 99%; Air Force - 92%) with the exception of railway workers (NRZ) and sugar plantation workers (Triangle); only 28% of male railway workers and 31% of female railway workers could cite two preventive methods. Knowledge levels for sugar plantation workers was extremely low: 5% for males and 7% for females. Triangle Ltd., however, is located in a fairly remote area with limited access to IEC campaigns. This will be a significant group to follow up with a second data point after AIDS prevention interventions have been in place. Sources of information on HIV/AIDS varied considerably depending on the population surveyed. Generally, more urban and more highly educated non-CSW populations tended to use television and newspapers as sources of information, while more rural and less educated populations relied on radio, friends, and health workers. Among the armed forces population, the AFZ showed a high reliance on newspapers relative to radio and other sources. Overall, radio was the most important source with 65% of respondents naming this as a main source of information, followed by television, friends and newspapers, (30-38%). CSWs reported health workers as a significant source of information, but still rated radio the highest. Youth also reported radio as a significant source, but rated television, newspapers, health workers, friends and school as important. Perception of Risk of HIV Infection Despite the high levels of knowledge of HIV/AIDS, respondents in all the study populations underestimated their chances of getting infected with HIV. Sixty-three percent of male commercial farm workers and 58% of females considered themselves at no risk of getting HIV in 1995. In 1997, the numbers for both showed a decrease; 44% for men and 33% for women. Correspondingly, there was an increase in the proportion reporting some perceived chance of HIV infection, indicating a growing understanding of the risk factors and their exposure to them. For transport workers, this figure (no chance of getting AIDS) was 53% at baseline and 30% at follow-up. Forty-five percent of the CSWs on the NECTOI routes considered themselves at no risk in 1995, decreasing to 13% in 1997. Forty-six percent of men and 34% of women workers at NRZ considered themselves at no risk of getting AIDS. For sugar plantation workers, 52% of men and 40% of women believe that they were at no risk. Women in this sample perceived themselves more vulnerable to HIV infection than men, with married women perceiving a higher risk than single women. Generally, married women were least able to assess their level of risk. That is particularly so because most women feel that since they are monogamous, they are infected by promiscuous men whose behavior they are not sure of. Unlike married women, single women reported that they are able to negotiate protection with their sexual partners who cannot force them to engage in unprotected sex. In the armed forces 82% of the Army, 67% of male Air Force and 63% of female Air Force surveyed considered themselves at no risk of getting AIDS. Peer education messages include the incidence of STIs as a risk factor for HIV infection, and although the military does not reveal statistics on STIs, anecdotal evidence suggests rates are high. A second data point, therefore, should indicate an increase in risk perception as this correlation is acknowledged. In addition to the studies conducted for FHI/AIDSCAP, it was found that despite reasonable knowledge and awareness, risk behaviors still persisted, especially among the younger and more knowledgeable respondents. While general information on HIV/AIDS was reasonably high, specific information on transmission was variable. Research was conducted in 1992 to study the psycho-social predictors of preventive behavior among general population adults in Bulawayo using the Health Belief Model to establish whether the association of the six elements of the model would lead to a reduction in high-risk related behaviors. The study found that perceived social support for behavior change, followed by accessibility of health care and advice, was the most consistent predictor of safer sexual behavior. At the same time, one man expressed the inevitability of men seeking out prostitutes but apparently did not associate this behavior with his own risk status: "You know, poverty is the main cause of prostitution. When we men find it extremely necessary to supplement our salaries, we tend to steal. Women sell their sex and we men fall as ready and willing prey." (Mhloyi, p. 33) Sexual Behavior and Partner Networking Numbers reporting two or more non-regular partners in 1995 varied between 0.6% among women on the farms to 7.6% among men to 13.3% among male transport workers. These numbers were targeted to decrease by 25% in 1997, according to the original project logframe. The two data points, however, were not comparable as the researchers posed this question differently in the two studies: the baseline figures only refer to the three most recent sexual partners. At the second data collection point, respondents were asked to refer to sexual partners they had had in the last three months. Neither of these questions provide PI 4 data which uses the time frame "in the last 12 months." It is also significant to note that in the 1995 survey 91.8% of male and 99.1% of female questionnaires had missing values on partner classification. The data collected in 1995 on CFU youth does not provide numbers with non-regular sexual partners but rather numbers with "two or more partners in the last 12 months:" 46% for males and 30% for females. Without PI 4 data to provide the denominator for PI 5, we can only measure "condom use in last sexual encounter." These figures were 53% for males and 63% for females. The same indicator was measured in 1997 and resulted in 21% of males and 7.6% of females. The level of non-regular partners in 1997 was down to 28% of males and 8% of females, so it could be concluded that youth were using condoms less because they had fewer casual partners. There was also a significant drop in condom availability, however. Condom Availability and Use The two most common methods given across target groups as examples of behavior change since hearing about AIDS were condom use and partner reduction. Behavioral studies carried out by other agencies on other populations have reflected the same. For example, among the CFU population 47% of men stated they have started using a condom and 38% said they are sticking to one partner; within NECTOI 46% of turnboys say they "will" use condoms, and 56% of drivers "will" stick to one partner; among the Army 24% said they have started using condoms, and 74% said they now stick to one partner (although the researchers have reason to doubt self-reporting). Data collected in the 1994 DHS showed 23% of men and 4% of women in the general population reported they started to use condoms; 34% of men and 10% of women reported sticking to one partner, and 23% of men and 79% of women said they had not yet changed their behavior. Among the CFU target population, the proportion of persons who can acquire a condom dropped for adult females and for youth by 10% or more, but remained stable at 77% for adult males. Condom use remained stable for adults at 50-57% with last non-regular partner, but for youth fell from 53% to 21% for males and from 63% to 7% for females. Once again, however, it is important to note that in 1995 the denominator for PI 5 was not obtained, i.e. respondents were asked if they had two or more partners but did not specify non-regular partners. They were then asked if they used a condom in last sexual encounter, but not necessarily with a non-regular partner. Hence, the figures for 1995 are expected to be much higher and do not in fact measure PI 5. Condom availability increased for truck drivers and their assistants at NECTOI- from 81% to 84% and commercial sex workers from 61% to 81%. Reported condom use increased for drivers from 72% to 80% and decreased for CSWs from 82% to 73%, so it is unclear with whom the drivers are using condoms. The results of the focus group discussions for both CFU and NECTOI highlighted barriers to condom use such as beliefs that condoms are painful and cause AIDS, and that suggesting the use of a condom with a regular partner indicates lack of trust. CSWs reported that financial issues were a major determinant of the number of sexual partners and whether or not condoms were used. Most drivers expressed their reluctance to use condoms after paying CSWs large sums of money. One said: "Having sex with a condom is like buying a sweet and putting it in the mouth with a paper wrapped on it." The sentiment expressed by many drivers was that the more they paid, the more skin contact they wanted. CSWs expressed this as their main fear. Thus, more money was associated with unprotected sex. "You know, there are certain prostitutes here who are known to go out with top brass guys only, the engineers [of NRZ]. You always want to have an opportunity to have sex with such a prostitute and more than often their charges are very high. When I save my monthly salary so that I can afford her, sure when that chance comes I can only have it straight (without a condom). I have to really enjoy the worth of my monthly wage." (Mhloyi, p 32) Peer educators also expressed fatigue and demoralization, stating that they were unable to continue their level of activities without more incentives or additional income, hence there may have been a lapse in message dissemination. Condom availability was very high for the military. Ninety-six percent of the Army and 97% of the Air Force indicated that they could obtain condoms if they needed them. Twenty-one percent of the Air Force service people reported condom use in their most recent sexual intercourse with a non-regular partner in 1995. For the Army, this figure was 44%. At Triangle and the surrounding community, 12% of CSWs and 92% of married men said that they had access to condoms. Forty-two percent of men and 43% of women reported condom use in their most recent act of sexual intercourse with a non-regular partner. For CSWs, this figure was 97% which may indicate that their partners provide the condoms, and the CSWs' interpretation of "access" is that which they can procure by themselves. Ninety-three percent of railways workers reported that they could have access to condoms on the day of the survey. Respondents in Harare were least likely to know where to access a condom, with only 52% reporting they could. Women were more likely to know where to obtain condoms than men (94%). Fifty-eight percent of the men and 47% of the women reported using condoms in their most recent sexual intercourse with a non-regular partner. Conclusion Although all of the outcome indicators for which data has been collected are not comparable, at least one behavioral data point has been established for each target group. These, together with a second data point established two years later for commercial farm workers, youth, transport workers and CSWs suggest that AIDSCAP/Zimbabwe contributed to the dissemination of messages on AIDS prevention in the areas where interventions were in place. On the sugar plantation, Triangle Ltd., where the project was in the first stage, baseline data showed that effort needs to be made to raise knowledge levels significantly. In other areas, in the next several years, it will be necessary to focus interventions on utilizing the information people already have to bring about behavior change. Continued collaboration with the government of Zimbabwe and other NGOs will also be necessary to ensure that condoms are available and accessible to support the condom use promotion strategy. Risk perception is generally underestimated, and it will be important to clarify and strengthen the understanding of the link between high risk sexual behavior and chances of HIV infection. |
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