Background
Zambia is one of the countries hardest hit by the HIV epidemic. HIV rates are particularly high along major highways and border posts. In 2000, a project was initiated with truck drivers and female sex workers at five of the major border posts and truck stops, namely Livingstone, Chirundu, Chipata, Kapiri-Mposhi and Kasumbalesa. The project is implemented by World Vision International in collaboration with other institutions and aims at behaviour change through peer education, social marketing of condoms and improved sexually transmitted infections (STI) care.
As part of the project, behavioural surveillance is done by the yearly repetition of a behavioural survey in both female sex workers and truck drivers in three of the five sites, using the methodology of the 'Behavioural Surveillance Surveys' (BSS) developed by Family Health International (FHI). The Tropical Disease Research Centre (TDRC) was contracted to implement the surveys with technical assistance from FHI's IMPACT project. The main objectives of the first round of the behavioural survey in truck drivers was (1) to provide baseline data for the measurement of the impact of the combined HIV prevention efforts, (2) to provide information to help the programme planning, and (3) to help establish a monitoring system that will track behavioural trend data for high risk and vulnerable target groups that influence the epidemic in Zambia.
Methodology
At the three selected sites, Livingstone and Chirundu at the Zambia-Zimbabwe border and Chipata at the Zambia-Malawi border, the main locale for the congregation of long distance truck drivers (LDDs) was identified. This was normally at the border itself. Between February and April 2000, all LDDs aged 18 and older passing through during the day were invited to participate until the desired sample size was obtained. Those LDDs who consented to take part were administered a standardised questionnaire that was based on the BSS prototype.
Results
In total 902 men were contacted at the three border sites (300 in Livingstone and 301 each in Chirundu and Chipata). A total of 867 (96%) had sufficient questionnaire data.
The mean age of participants was 37 years, the great majority (88%) had completed at least primary school (7th class) and most (86%) were currently married. In Livingstone and Chipata more than half of the drivers (61% and 54% respectively) were Zambians, but this was not the case in Chirundu where most were Zimbabweans (58%). Other common nationalities among the participants were South-Africans (8%) and Malawians (7%). About two thirds of the drivers (67%) reported being away from their home more than one month a year and that they cross the border on average 5 to 6 times in a three-month period.
The great majority of respondents (99%) were sexually active, the median age of sexual debut was 18 years and of those who were sexually active, almost all (97%) had sexual intercourse in the past 12 months. The median number of sexual partners in those 12 months was 2, with almost half (46%) reporting only one partner. Of those drivers who reported sexual intercourse in the past 12 months, almost all (99.7%) had intercourse with a 'regular' partner. Almost one third (30%) reported intercourse with at least one 'commercial' partner and 22% with a 'non-regular' partner. The reported frequency of sexual intercourse was a median of 6 times per month with a regular partner and 3 times per month with a commercial partner and with a non-regular partner.
Reported condom use at the last sexual contact was 19% with a regular partner, 75% with a non-regular partner and 92% with a commercial partner. Almost three quarters (71%) reported they never used condoms with their regular partner, 59% said they always or almost always use a condom with a non-regular partner and 80% said they always use condoms with a commercial partner. As reason for not using a condom with a regular and with a non-regular partner they most frequently mentioned they didn't think it was necessary (55% and 43% respectively).
Almost two thirds of the men reported to have ever used a condom (63%) and almost all (97%) knew where they could be obtained. The places where condoms can be obtained most often mentioned were shops (76%), a clinic or hospital (64%), a bar, guesthouse or hotel (53%) and pharmacies (40%). Almost all men (98%) reported that they could obtain condoms in less than 1-hour time.
Most men (96%) had ever heard of 'diseases that can be transmitted through sexual intercourse' and 73% of these men could mention at least two symptoms of STD in men and 52% at least two STD symptoms in women.
About one tenth of the men (9%) reported to have had either a genital discharge (7%) or genital ulcers or scores (6%) in the past 12 months. Two thirds (69%) of these sought advice at a health facility. One quarter (25%) sought advice from a traditional healer, 18% from a pharmacist, 8% bought capsules on the street and 13% took medicines at home. Slightly more than one third (38%) said they told their partner, 44% stopped having sex and 22% used condoms while symptomatic.
Most men (81%) knew someone who had HIV/AIDS. They generally knew that HIV could be transmitted by infected needles (95%) or from mother to child during pregnancy (91%). That it also could be transmitted through breastfeeding was less known (69%). Still 17% of the men thought mosquito bites could transmit HIV and 6% believed sharing meals was sufficient to get infected. Most men (96%) were aware that a healthy looking person could be infected with HIV. The way to prevent HIV best known was abstinence (90%), followed by faithfulness (84%) and condom use (76%). Only 11% of those who knew that HIV could be transmitted from mother to child also knew that treating pregnant infected women could prevent this infection.
Most men (92%) reported to have access to an HIV voluntary counselling and testing facility. More than a quarter (30%) said to have ever been tested. Of these, about one third (35%) said it was not on a voluntary basis, and 9% did never found out the result.
Five behavioural indicators were defined as project indicators. Indicator 1 measures knowledge of STI symptoms (71% of the men could at least cite two major STI symptoms in men), indicator 2 measures knowledge of HIV prevention (89% could mention at least two HIV prevention strategies), indicator 3 measures condom availability (98% reported easy access to condoms), indicator 4 measures condom use with commercial partners (92% of the men reported that they used a condom in the last commercial sex act) and indicator 5 measures condom use with casual partners (75% reported that they used a condom in the last sex act with a non-regular partner).
Discussion and conclusions
The truck driver population surveyed was international, urban, middle aged, mostly married and similar to the general population in terms of educational level and religion. Most of them were a significant proportion of their time on the road.
About half of them had an at-risk risk sexual behaviour, with multiple sex partners. Knowledge and behaviour related to HIV and STD was generally good and condoms are reported to be available. Condom use was reported to be very high with commercial sex partners, moderately high with non-regular partners and low with regular partners. Knowledge and behaviour on STD symptoms was moderate and the availability and utilisation of counselling and testing facilities needs to be further explored.
The WVI project should focus on behaviour change, by peer and other education, and on further exploring and enhancing condom use both with commercial and casual partners. Knowledge and care seeking for STD symptoms could be improved by the behaviour change activities, by improving the access to and the quality at selected health facilities at the truck stops, by developing treatment facilities at the trucking companies and eventually by involving non-formal service providers such as private practitioners and pharmacists and by providing treatment facilities at the truck stops outside the health facilities. The possibility for offering HIV VCT facilities should be further explored.
