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SummaryRegional Assessment There is growing recognition that interventions for highly HIV vulnerable communities are vital, even in a mature HIV epidemic. The link between mobility and HIV vulnerability is also increasingly recognized, and highways and borders have been identified as environments of elevated HIV vulnerability. For example, prevalence of HIV among antenatal clinic clients at Beitbridge -- southern Africa's major border crossing -- is nearly 50 percent. Because migration transcends national and international boundaries, HIV/AIDS interventions for mobile populations require a regional approach. Recognizing the importance of regional cooperation, the U.S. Agency for International Development (USAID) and partner governments and organizations initiated the "Corridors of Hope Initiative." This project seeks to promote practical regional collaboration, beginning on the Durban-Lusaka highway, southern Africa's major transport corridor linking South Africa, Zimbabwe and Zambia. A regional assessment for the Corridors of Hope Initiative sought to develop, test, refine and package a standard assessment methodology that would enable planners to evaluate risk, identify prevention opportunities and develop grounded, coordinated regional prevention initiatives. This assessment was conducted from July to November 1999 at four border sites in three countries: Messina in northern South Africa, Beitbridge in southern Zimbabwe, Chirundu in northern Zimbabwe and Chirundu in southern Zambia. Members of the seven-person research team began by conducting a literature review of regional sociocultural and epidemiological data from Zambia's Central Board of Health, Zimbabwe's National AIDS Coordination Programme and South Africa's National AIDS Directorate. They also mapped the four sites, producing maps that provide a spatial representation of borders, highways, health and social services, major residential areas, major army and police bases, major employment centers, major truck stops, and sex worker residential areas, guest houses and bars. Detailed inventory guides were prepared to gather information, including demographic, residential and employment data. Team members used these guides to compile information about the trucking companies using the routes, the average number of trucks crossing and parked overnight at borders, the average duration of border stops, the overall duration of truckers' journeys, and the guest houses, bars and streets patronized by truckers. They obtained similar information about informal traders and sex workers, as well as data on other major economic activities in the four sites. They also collected data on educational institutions and health services, including management of sexually transmitted infection (STI), numbers and categories of STI patients seen, and major impediments to effective STI management. Ethnographic studies on the sexual context of risk at the border posts focused primarily on migrant men and women, including truckers, sex workers, and male and female traders. The researchers also conducted short behavioral surveys among sex workers in three of the sites: Chirundu and Beitbridge in Zimbabwe and in Messina, South Africa. The surveys focused on STI/HIV knowledge and risk perceptions, relations with steady, casual and commercial sex partners, condom use with each category of partner, and STI symptoms and care seeking. Findings Messina, South Africa Messina has an estimated population of 19,500 to 26,000 residents, two-thirds of whom are female. Situated over 500 kilometers north of Johannesburg in South Africa's Northern Province, Messina is the definitive example of an HIV-vulnerable context. It has an army base to patrol the porous northern border (Africa's "Rio Grande"), copper and diamond mines with migrant mineworkers, and a vast trucking industry. It also has a large sex work industry, which attracts sex workers from the Northern Province -- by far South Africa's poorest province -- and adjacent areas of Mozambique and Zimbabwe. The primary source of local employment is farming, with the large army base, the major mines and informal trading also playing a role. Several thousand truckers cross and sleep at the border each month. Messina has approximately 400 resident sex workers, with about 300 part-time sex workers coming in at peak periods. Members of the local clinic staff have been trained in syndromic management of sexually transmitted infections and receive STI drugs, albeit erratically, but they see few sex workers or truckers. Messina has large private and traditional health sectors. Neither public (government-supplied) nor socially marketed condoms are easily obtainable, except through a targeted peer education project for sex workers managed by the Centre for Positive Care. This nongovernmental organization (NGO) carries out projects with sex workers in the Northern Province towns of Njele, Louis Trichardt, Mutali and Messina with technical support from Oxfam, the Mpumalanga Project Support Association and the University of Zimbabwe and financial support from Oxfam, the Norwegian Agency for Development (NORAD) and the Swedish International Development Agency (SIDA). Beitbridge, Zimbabwe Beitbridge town has an estimated population of 20,000 residents. It is situated over 500 kilometers from Harare in Zimbabwe's Matabeleland South Province. The major source of local employment is farming, with customs and immigration, the uniformed services, and formal and informal vending also playing a role. A diamond mine recently closed, increasing unemployment and poverty. Several thousand truckers cross the border monthly. The area has approximately 500 resident sex workers, with about 200 part-time sex workers coming in from arid rural Masvingo and Matabeleland South at peak periods. District clinic staff members have received syndromic management training and have moderate supplies of STI drugs, but they see few truckers. Public and socially marketed condoms are generally obtainable. A targeted peer education program for sex workers is managed by a multisectoral district committee, with technical support from the KweKwe Town Council and the University of Zimbabwe in Harare and financial support from SIDA. The National Employment Council for the Transport Operating Industries (NECTOI) carried out a truckers' HIV/AIDS project from 1994 to 1996 under FHI's USAID-funded AIDS Control and Prevention (AIDSCAP) Project, but currently there are no interventions specifically for truckers. One-half or more of Beitbridge's antenatal patients are already infected with HIV. Chirundu, Zimbabwe This town has an estimated population of 2,700 to 4,000 residents. It is situated over 350 kilometers north of Harare, in Zimbabwe's Mashonaland West Province. The major sources of local employment are farming and fishing, with customs and immigration, the uniformed services and informal vending also playing a role. Every month several thousand truckers cross the border at Chirundu, and over 1,000 truckers sleep there. The area has approximately 100 resident sex workers, with another 200 part-time sex workers coming in from Kariba, Makuti, Karoi and rural Urungwe and Magunje at peak periods. District clinic staff members have received syndromic management training and have reasonable supplies of STI drugs, but they see few truckers. Public and socially marketed condoms are obtainable. A multisectoral district committee manages a targeted peer education program for sex workers, with technical support from the University of Zimbabwe Lake Kariba Research Station and the University of Zimbabwe in Harare and financial support from SIDA. The AIDSCAP/NECTOI project also covered Chirundu from 1994 to 1996, but currently there are no HIV/AIDS interventions specifically for truckers. Chirundu, Zambia With a population of 7,000 residents, Chirundu, Zambia, is also a relatively small site. It is situated over 140 kilometers south of Lusaka, in the poor, marginal Chiawa area of Zambia's Southern Province. The main local employment is with customs and immigration, the uniformed services, nearby banana farms and in informal trading. Every month several thousand truckers cross the border, and over 1,000 truckers sleep there. The area has approximately 300 resident sex workers, with another 200 part-time sex workers coming in from rural Chiawa at peak periods. The only hospital is Mtendere Catholic Mission Hospital, which is now taking increasing interest in STI/HIV work but serves few STI patients. Staff members have received training in STI syndromic management, but drug supply is erratic. Public and socially marketed condoms are in short supply. Mtendere Hospital has undertaken a small community peer education project in adjacent Siavonga District with support from Harvest Help, a rural community support NGO based in the United Kingdom. Summary of data from the four border sites
Conclusions and Recommendations There is exceptional HIV vulnerability at each border post, with a sociocultural context of acute female poverty and male and female mobility, spearheaded by truckers and traders. Further interventions are urgently needed to complement past and existing work at the borders. While sex workers are addressed at three of the sites and will soon be addressed in Chirundu, Zambia, there are other critical needs in HIV/AIDS prevention. A major gap is the lack of interventions for truckers. Such interventions are urgently needed, both at the borders and perhaps through major regional trucking companies in Johannesburg, Harare and Lusaka. There is also great scope to address members of the permanent border communities, who may have sexual relationships with migrant populations. During the assessment, key informants repeatedly highlighted the links between permanent and migrant communities. They cited several forms of sexual relationships, but two topics received particular emphasis. One was the vulnerability of schoolgirls and other young women who have migrant partners for economic reasons. The second was the relationships that occur between men in formal employment at the borders -- including members of the uniformed services, border officials, miners and agricultural workers -- and HIV-vulnerable women, such as sex workers and female traders. There is thus a sound rationale for broadening interventions to reach key audiences among permanent residents at borders, particularly young women and men in formal employment. A comprehensive prevention program is needed to create an enabling environment for lower HIV risk. Core services of such an approach include: strengthened STI services to reduce sexually transmitted infections; targeted interventions to protect truckers and their partners; workplace interventions to reduce HIV transmission in influential and economically strategic populations; youth interventions to prevent adolescents from contracting HIV; and condom social marketing and targeted communication interventions to promote and provide a supportive and reinforcing environment for behavior change. STI care needs to be improved for both sex workers and clients at each of the borders. Innovative strategies involving both the public and private sectors may be required to reach truckers, who experience symptoms but do not use public health services at the borders. In contrast, sex workers have a large burden of asymptomatic STIs that will not be detected through standard syndromic approaches. It may be necessary to promote regular screening for sex workers and the use of special STI protocols, including additional diagnostics and risk assessment. It may also be worth exploring presumptive treatment approaches, at least initially. Condoms are generally difficult to obtain, particularly in Chirundu, Zambia, and Messina, South Africa, and to a much lesser extent in the two Zimbabwean towns. There is great scope for increased condom social marketing, particularly in South Africa's Northern Province. Finally, it is important to establish simple, effective project evaluation and quality assurance systems. A modified behavioral surveillance survey may be needed for outcome assessment. |
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