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Regional AssessmentUSAID mission directors and health, population and nutrition officers met in October 1998 to review the HIV/AIDS epidemic in southern Africa. The group recognized the important opportunities for HIV/AIDS prevention activities in southern Africa and identified three priorities for regional action:
One result of that meeting is a regional HIV prevention initiative to be undertaken initially along the Durban-Lusaka highway -- southern Africa's major highway -- focusing on the Messina-Beitbridge border between South Africa and Zimbabwe and the Chirundu border between Zimbabwe and Zambia. It is hoped that this initiative, named "Corridors of Hope," may later be extended to other highways throughout southern Africa. The regional Corridors of Hope Initiative is consistent with growing recognition that interventions for highly HIV-vulnerable communities are vital, even in a mature HIV epidemic. The link between migrancy and HIV vulnerability is also increasingly recognized, and highways and borders have been identified as environments of elevated HIV vulnerability. Because migrancy transcends national and international boundaries, HIV/AIDS prevention efforts among mobile populations require a regional approach. Following the October 1998 meeting, USAID asked Family Health International and Population Services International (PSI) to conduct an assessment for the regional Corridors of Hope Initiative. This report summarizes the findings of that assessment. Purpose The purpose of the regional assessment was to:
The Research Team On behalf of USAID, the FHI-managed Implementing AIDS Prevention and Care (IMPACT) Project sent a seven-person team to conduct the assessment in four border areas -- Messina, South Africa, Beitbridge, Zimbabwe, Chirundu, Zimbabwe, and Chirundu, Zambia -- from July to November 1999. The minimum qualification of all team members was an honors degree in social science. Team members were also chosen for language competency. As a result, the team included speakers of all six major languages spoken at the four borders: chiVenda, siZulu, siNdebele, chiShona, chiNyanja and chiGoba. The research team received intensive training in survey methods, participatory learning appraisal, mapping, and ethnographic and inventory research. The researchers also received careful field supervision and support from Zimbabwe's Project Support Group. Methodology A key feature of the methodology was the development of structured assessment tools that may be used in other border, highway and risk contexts. The methodology also emphasized community-driven participatory approaches, which build local involvement and ownership. The research team sought to use multiple data collection methods to enrich understanding and to triangulate and validate findings.
Data Review The team began by reviewing the existing data. The desk review consisted of an extensive search and review of the published and gray literature, including the electronic literature. The literature search and review focused on:
Policymaker Interviews Team members also interviewed regional, national and provincial policymakers in Zimbabwe, Zambia and South Africa, including donor representatives, health employees, AIDS program staff, NGO staff, and experts in STI management, behavior change communication, and condom promotion and distribution. These interviews focused on policy and program priorities. Field Research The largest component of the assessment was the field research, which took place at each of the four border sites and in contiguous towns and rural areas. It included site inventories, in-depth interviews, focus group discussions, ethnographic observation and analysis, participatory learning appraisals, mapping and behavioral surveys. Site inventories An important part of the assessment was the careful enumeration of facilities, resources, agencies and communities at each of the sites. Accordingly, team members developed, pilot tested, revised and finalized a structured site inventory, which was used to collect demographic and socioeconomic data, as well as information about vulnerable populations and HIV/STI services, at each site. The inventories were completed by gathering data from official district and municipal records and interviewing a wide range of people, including district and municipal staff, business owners, union leaders and employees, trucking and freight company management, members of the uniformed services, police, immigration and customs officials, health workers, sex workers, truckers, bar patrons and informal traders. Information from different sources was carefully triangulated to verify findings.
Interviews and group discussions The structured, highly formal inventory data was complemented by information from detailed, semi-structured key informant interviews. In these interviews, team members did not focus on collecting quantitative data, but sought to understand the social and sexual context and the processes of risk behavior at border sites. The interviews addressed casual and commercial sex, with particular reference to sex workers, informal traders, and truckers and other mobile men. Key informants included sex worker peer educators, formal and informal sex worker leaders, trucking company managers, experienced truck drivers, informal traders, miners, bar owners, health workers, and police, immigration and customs officials. Interviews with these key informants provided an important source of information for triangulation of data. In addition to asking experienced informants about other people's behavior in the key informant interviews, team members conducted semi-structured in-depth interviews that focused on each participant's own behavior. Detailed interviews were held with sex workers, truckers, informal traders, customs and immigration officials, members of the uniformed services and miners. Focus group discussions are a useful addition to individual interviews with key informants or participants. Such discussions were held at each border site with sex workers, truckers and members of the general population. PRA/PLA Participatory rural appraisal (PRA), or participatory learning appraisal (PLA), techniques were also used. For example, researchers took transect walks with sex worker peer educators, sex workers, truckers and traders to see the community through their eyes, identify key sites and learn more about what happens at each site. Participants, including sex workers and truckers, also completed seasonal calendars in which they described their lives at different periods of the week, month and year. This technique is helpful in identifying temporal factors that may be associated with increased sexual vulnerability. In Chirundu, Zambia, for example, women seek an income from sexual partnerships in the winter when the meager Chiawa rural harvest is depleted. Peer educators and community members participated in community mapping exercises, in which they identified risky places, sexual meeting places, sex work neighborhoods, and where people seek health care, including STI care, in their communities. Body mapping (in which, for example, a respondent is asked to draw a diagram of his or her body describing the perceived location of internal organs) was also used. This method aided the researchers in exploring cultural beliefs about sexuality, the effects of condom use, sexually transmitted infections and disease with sex workers, truckers and members of other groups in the communities. Mapping In addition to the informal mapping undertaken as part of the PRA/PLA exercise, the research team formally and systematically mapped sites in conjunction with health workers, sex worker peer educators and community members. Maps were obtained from the Messina Transitional Local Council for Messina and the Zimbabwe Surveyor General for Beitbridge. Maps of Chirundu could not be obtained and were drafted by the research team. Team members and their counterparts at each site undertook the mapping by first driving, then walking, throughout each border site. During the mapping, research staff developed detailed lists and noted the locations of health and social services, churches and community organizations, sex worker neighborhoods, transport routes, markets, hotels, bars, bottle stores, workplaces, construction sites, military bases, truck stops, border posts, border officials' residences and neighboring farms. The mapping was accompanied by preliminary zoning, in which research staff looked for discrete, manageable geographic clusters, based on size, population, transport flows and micro-cultures. These preliminary zones, which will be refined later, may form the basis for subsequent project implementation. Behavioral surveys Behavioral surveys were undertaken among sex workers at Messina, Beitbridge and Chirundu, Zimbabwe. They were not administered at Chirundu, Zambia, because an FHI/IMPACT behavioral surveillance survey (BSS) was to begin there shortly, and conducting another survey before the BSS might contaminate its results. The behavioral survey conducted at the other three sites was developed and revised in English by a team of social scientists, translated into local languages, revised for clarity and politeness, reviewed by health workers, back-translated into English, pilot-tested and finalized. The short survey form, based on FHI's BSS and UNAIDS multicenter survey, was designed to collect information on STI/HIV knowledge and risk perceptions, discussion about AIDS, stable, casual and commercial sex partner relations, condom use with different categories of partners, STI symptom knowledge, recent STI symptoms, and STI care-seeking practices. The survey was described as a health survey, rather than an AIDS survey, to minimize anxiety and the desire to provide the expected answers. It was designed to be 15 minutes long, with sensitive sexual behavior items at the end. Experience shows that surveys less than 10 minutes long do not create sufficient rapport to elicit accurate responses about sexual behavior. Surveys over 15 minutes long can be intrusive. The results of the behavioral surveys are summarized in Appendix 1. Data analysis Detailed inventory data for each site were tabulated, analyzed individually and compared. Data from each site of shared borders were compared for consistency. Survey data were entered into SPSS 7.0, range checked, edited, cleaned and analyzed. Mapping data were entered on draft maps, revised and then entered on final version maps. Key informant interviews, participant in-depth interviews, focus group discussions, ethnographic observation and participatory rural/learning appraisals were summarized and integrated to provide a comprehensive ethnographic analysis. |
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