Conclusions and Recommendations

There is exceptional HIV vulnerability at each of the four border posts, with a sociocultural context of casual and commercial sex and profound mobility, as truckers, traders, soldiers, migrant miners and itinerant sex workers move through the towns.

Further interventions are urgently needed to complement existing HIV/AIDS work at the borders. Sex worker peer education interventions are established at three border posts -- Messina, Beitbridge and Chirundu, Zimbabwe. However, there are profound needs and few other interventions at the borders.

Above all, there are few initiatives for truckers. The contribution of truckers to STI/HIV vulnerability at the borders has not been exaggerated. Trucking routes have totally altered the character of border towns. Several thousand truckers cross the major borders each month, and their incomes eclipse local resources. At some borders, the number of truckers crossing each month exceeds the stable adult population of the entire border site.

As noted before, both sex workers and truckers are important bridge populations in the sexual networks linking transient and residential communities. There is thus a need for interventions among residential communities linked to these and other bridge populations.

Three priority residential communities may be identified: young women, men in occupations other than trucking and low-income women at border posts. The HIV vulnerability of young women, including schoolgirls and young vendors, who seek an income from commercial or casual sex with truckers and other groups of older men with income is distressingly high. At each site, communities expressed concerns about young women, particularly schoolgirls. Men in occupations other than trucking visit sex workers and thus share the sexual networks of sex workers and truckers. And low-income women at the border posts may share sexual networks with sex workers and truckers through their own or their partners' sexual relationships. Beitbridge's antenatal HIV prevalence of approximately 50 percent illustrates how widely the virus is disseminated.

A number of priority interventions require greater emphasis: strengthening STI services; improving condom promotion and distribution; and supporting and reinforcing behavior change through targeted media and community mobilization. It will also be important to establish simple, effective project evaluation and quality assurance systems. A modified behavioral surveillance survey is needed to measure trends in HIV risk behavior over time.

Although STI care services are offered at each border, there are opportunities to strengthen services. At some borders, health workers need training in syndromic management and improvements in drug supply. Outreach and communication initiatives are also needed to promote appropriate STI care-seeking responses at all the border sites.

Innovative strategies are required to tailor STI care to meet the needs of the different priority groups identified in this assessment. For example, sex workers' STI needs will not be addressed by syndromic STI care alone because they have a large burden of asymptomatic infection, which standard syndromic approaches do not detect. Regular screening, with increased use of diagnostic tests or presumptive treatment, may be required. Truckers, in contrast, may have symptoms but may not seek care or may visit private or traditional providers, who may not necessarily cure them. Therefore, initiatives to improve private and traditional providers' STI care are important. It may also be worth taking STI care to truckers by establishing services at the sites and times they prefer. Others in primarily male occupational groups, such as soldiers, miners and farm workers, may face similar challenges and require similar responses. To reach youth -- particularly young girls -- adolescent-friendly reproductive health services are required.

All of these services will require intensive behavior change communication to generate demand. There are no targeted media or community mobilization initiatives at the border sites. Such initiatives could be used to promote an enabling environment for behavior change, condom use, and STI prevention and care-seeking because border sites are compact and it is easy to identify the sites and routes used by different target groups.

There is also scope for improving promotion and distribution of public and socially marketed condoms at all four border sites. Public sector distribution in South Africa and Zimbabwe occurs through health centers and sex worker peer educators. There is condom social marketing at Beitbridge and Chirundu in Zimbabwe, limited condom social marketing in Chirundu, Zambia, and almost no social marketing in Messina, South Africa. (Northern Province is not yet a focal province for South Africa's Society for Family Health.) Intensive social marketing, with particular emphasis on truckers, is needed.

The border sites may be divided into larger and smaller sites. The southern sites of Messina and Beitbridge are approximately four times larger than the northern sites, Chirundu, Zimbabwe, and Chirundu, Zambia. The southern sites -- particularly Messina -- have relatively diverse workplaces and several schools. The northern sites have few large workplaces and only one school each. Thus, a greater share of prevention resources is likely to be directed to the southern sites.

Appendix 1. Behavioral Survey Results

Behavioral surveys were completed among sex workers in three of the sites. Key survey data are summarized below for each site.

Percentage of sex workers reporting HIV-preventive and HIV-risk behaviors and STI symptoms in three border sites

Reported behavior or experience	Messina	Beitbridge	Chirundu, Zimbabwe
	% Yes	% Yes	% Yes
Attended peer education	35	40	55
Received condoms from peer	78	89	91
Have steady boyfriend	81	61	61
Used condom with boyfriend	42	73	86
Had casual partner	40	74	51
Used condom with last casual partner	36	44	65
Had regular client	39	87	63
Used condom with last regular client	38	41	72
Had non-regular client	N/A	89	53
Used condom with last non-regular client	N/A	89	70
Know STI symptoms	N/A	92	94
Seek care for STI symptoms	N/A	92	92
Had abdominal pains	N/A	20	35
Had discolored discharge	N/A	68	35
Had genital ulcer	N/A	14	34

Notes:
Excludes no responses.
A shorter questionnaire was used at Messina.
Chirundu, Zambia, was not included in survey.