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This document presents valuable data about HIV/AIDS-related knowledge, attitudes, and behaviors, based on specialized behavioral surveillance surveys conducted among female sex workers in Zambia in 2000.
Table Of Contents I. Executive Summary, Introduction and Objectives (See Below) II. Methodology III. Results V. Annex Executive Summary Background As part of the project, behavioural and biological outcomes are to be evaluated by repeated surveys. Behavioural surveillance is planned annually in both FSW and truck drivers in three of the five sites, using the methodology of the Behavioural Surveillance Survey' (BSS) developed by Family Health International (FHI). Biological impact is measured by a baseline and end-of-project survey of the prevalence rate of the major STI in FSW. 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 and the baseline biological survey were (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 The collected specimens included two self-administered vaginal swabs and a venous blood sample. One vaginal swab was inoculated into the InPouch culture medium for T. vaginalis and examined by microscopy at 12, 24 and 48 hours post-incubation. The other vaginal swab was directly placed in a cryovial, frozen and shipped to the Institute of Tropical Medicine (ITM) in Belgium for testing for N. gonorrhoeae and C. trachomatis using DNA amplification tests. Syphilis infection was identified serologically with a quantitative rapid plasma reagin (RPR) screening test, confirmed with a T. pallidum hemagglutination assay (TPHA). All sex workers were invited to present at a selected clinic the next day for a physical exam and enrolment in the STI care component of the project. They received treatment based on algorithms specifically designed for sex workers, free condoms and appropriate counselling. All women were asked to return to learn the results of their syphilis serology and T. vaginalis culture and to be treated accordingly. Results The study population was a very young one, with a mean age of 23 years and a high proportion (37%) of teenagers. Most (81%) had completed at least primary school (7th class) and were not married and living alone (69%), although almost half (48%) had ever been married. The distribution by ethnic group and religion was similar to that of the general Zambian population. The population was a mobile one with 46% original from a province other than the one currently residing in and a median period of current residence of 5.9 years. One third (33%) reported to have an occupation other than sex work. More than half (58%) said they were supporting others. The median age of sexual debut was 15 years and of starting sex work 17 years. Almost all women (99.5%) reported to have done sex work elsewhere before. The median time period of sex work in the current residence was 1.7 years. The median number of sexual partners in the last 7 days was 3. Most of these were paying clients (median 2). The median number of clients on the last day worked was 1. Only a small proportion of the women (6%) saw a high number of clients (more than 3) per day. The median price per client was 20,000 Kwacha (equivalent to 7 USD). Slightly more than half of the women (54%) claimed to have used a condom at the last sexual contact with a paying client. The most frequent reasons mentioned for not using a condom were that the client objected (36%), that they themselves didn't like it (21%) or that they didn't think of it (21%). When asked how regular they used condoms with clients over the last 30 days, 25% claimed to use condoms every time or almost every time, 59% sometimes and 17% admitted to never use condoms. Half (50%) of the women reported a non-paying partner in the last seven days. The median frequency of sexual intercourse with this partner was 4 times in the last 30 days. Less than half (44%) had used a condom at the last sexual intercourse with this partner and the majority reported to have used condoms with their non-paying partners during the past 12 months only sometimes (66%) or never (18%). More than one third (37%) of the women who have a non-paying partner reported that they were forced to sexual intercourse in the past 12 months by any of their sexual partners. Most women reported to have ever used a male condom (89%) and reported that they could obtain condoms in less than 1-hour time (94%). The places where condoms can be obtained most often mentioned were shops (72%), a clinic or hospital (65%), a bar, guesthouse or hotel (52%) and the market (46%). Most of the women however, did not have any condoms at hand at the time of the interview (77%). The female condom was lesser known by the women, although 60% had already heard of them. Of these, 19% had already used the female condom and 49% knew where to obtain them. Most women (96%) had ever heard of 'diseases that can be transmitted through sexual intercourse'. Seventy two percent of these women could mention at least two symptoms of sexually transmitted diseases (STD) in women and 61% could mention at least two STD symptoms in men. About one third of the women (36%) reported to have had either a genital discharge (24%) or genital ulcers or scores (28%) in the past 12 months. Three quarters (76%) of these sought advice at a health facility. Almost half (47%) sought advice from a traditional healer, 26% from a pharmacist, 24% bought capsules on the street and 27% took medicines at home. Less than half (43%) said they told their partner, 33% stopped having sex and 23% used condoms while symptomatic. Less than half (45%) of the women reported to use any family planning method. Of those who reported using a family planning method, only 59% used a method considered as effective for family planning. About one third of the women (32%) said they ever lost a pregnancy. Three quarters (75%) of the women knew someone who had HIV/AIDS. The women generally knew that HIV could be transmitted by infected needles (92%) or from mother to child during pregnancy (91%). That HIV could also be transmitted through breastfeeding was a little less known (82%). Still 22% of the women thought mosquito bites could transmit HIV, and 9% believed sharing meals was sufficient to get infected. Most women (93%) were aware that a healthy looking person could be infected with HIV. About fourth fifths of the women knew that HIV infection can be prevented by condom use (81%), faithfulness (80%) or abstinence (84%). Only 17% of those who knew that HIV could be transmitted from mother to child also knew that treating pregnant infected women could prevent this infection. About two thirds of the women (66%) reported to have access to an HIV voluntary counselling and testing facility. Twelve percent said to have ever been tested. Of these, about half (47%) said it was not on a voluntary basis, and one quarter (25%) never found out their result. Five behavioural indicators were defined as project indicators. Indicator 1 measures knowledge of STI symptoms (61% of the women could at least cite two major STI symptoms in women), indicator 2 measures knowledge of HIV prevention (85% could mention at least two HIV prevention strategies), indicator 3 measures condom availability (96% reported easy access to condoms), indicator 4 measures condom use with clients (54% of the women reported that they used a condom in the last commercial sex act) and indicator 5 measures condom use with regular partners (44% reported that they used a condom in the last sex act with a non-paying partner). All indicators were statistically significant (p<0.05) different by site. The women in Chipata performed consistently better than in the two other sites. The prevalence of gonorrhea, genital chlamydial infection, reactive syphilis serology and trichomoniasis was 19.9%, 6.7%, 29.3% and 48.9%, respectively. The prevalence of gonorrhea and syphilis was higher in Livingstone than in the other sites (23.2% and 36.5% respectively in Livingstone, 19.8% and 20.9% respectively in Chirundu and 28.7% and 16.0% respectively in Chipata). Discussion and conclusions The WVI project should focus on enhancing condom use, both male and female, through peer and other education programs with the sex workers, their clients and their regular partners. Knowledge and care seeking for STD symptoms could be improved by regular visits to trained health care providers in selected health facilities where access barriers have been reduced. These health facilities should also develop activities to enhance sex workers' use of family planning. The possibility of offering HIV VCT facilities should be explored further. Introduction Zambia is one of the countries hardest hit by the HIV epidemic. The 1998 antenatal surveillance found HIV prevalence rates of 27 percent in Zambia's major cities1. A Ministry of Health expert group estimated that provincial adult HIV prevalence was 26 percent in Lusaka, 23 percent in the Copperbelt and 19 percent in the Northern Province. National adult HIV prevalence is estimated to be 20 percent, which means that more than one million Zambians are infected with HIV. HIV rates are twice as high in urban areas as in rural areas. Rates are very high along major highways and borders and in trading centres, farming and mining towns. The 1998 surveillance reported rates of 31 percent in the border town of Livingstone and 27 percent in Chipata. In neighbouring Zimbabwe, very high rates are also observed in border towns. HIV rates among pregnant women are 60% in Beitbridge on the South African border and 45% in Victoria Falls on the Zambian border. Zambia's major highways run alongside the two major rail lines, from Livingstone to Kasumbalesa and from Kapiri Mposhi to Nakonde. Its major trucking borders are Chirundu, Livingstone, Chipata, Nakonde and Kasumbalesa and its major internal trucking town is Kapiri Mposhi, at the junction of the two railway routes. These six sites have an estimated population of 250,000 inhabitants, including 1,500 sex workers and an itinerant population of 2,000 truckers. Sexually transmitted diseases (STDs) are not well documented in Zambia. The number of reported STD cases rose from 190,344 in 1981 to 307,957 in 1992, the last year for which data are available. In community surveys, up to 10 percent of men report having had an STD in the past year. In a survey of 66,000 pregnant women screened in 1997 in five districts -- Chipata, Kitwe, Livingstone, Lusaka and Ndola -- 10 to 15 percent, with a mean of 12 percent, had syphilis. In a recent community based survey in Ndola, prevalence rates for gonorrhoea and genital chlamydial infection were approximately 2% in the general population and as high as 15% for gonorrhoea and 9% for genital chlamydial infection in female sex workers. Prevalence rates for trichomoniasis and syphilis were 29% and 14% respectively in the general population and 42% for both in sex workers2. This confirms that sexually transmitted diseases remain a major public health problem in Zambia. Data from the Demographic and Health Surveys (DHS) and other Knowledge, Attitudes and Practices surveys show that, although sexual behaviour seemed to have positively changed in the early 1990s, it has stagnated over recent years3. In a nation-wide sexual behaviour survey performed in 1998, 97% of men and 92% of women had heard of condoms and 90% and 76% respectively knew where to obtain them, but only 42% and 21% respectively had ever used condoms. Only 29% of men and 19% of women who had a non-regular partner in the last year used a condom at their last intercourse4. In a survey conducted with female sex workers in Ndola in 1997-1998, only 28% reported using condoms in their most recent contact with a client2. For these reasons, a project was initiated with high-risk populations at five of the major border posts and truck stops, namely Livingstone, Chirundu, Chipata, Kapiri-Mposhi and Kasumbalesa. The target populations are truck drivers passing through and female sex workers (FSW) operating around the stops. The project aims to change behaviour through peer education and social marketing of condoms, and to improve STD care. The project is implemented by World Vision International (WVI) in collaboration with the Government of Zambia, Society for Family Health (SFH), Tacintha and the Church Medical Association of Zambia (CMAZ). It receives technical support from Family Health International's (FHI) IMPACT project, and is funded by the United States Agency for International Development (USAID) and the Japanese International Cooperation Agency (JICA). The project's impact is evaluated by repeated measuring of some behavioural and biological outcomes. A behavioural survey is conducted yearly with both female sex workers and truck drivers in three of the five sites, using the 'Behavioural Surveillance Surveys' (BSS) methodology developed by FHI. Biological impact is measured by a baseline and end-of-project survey of the prevalence rate of the major STDs among female sex workers. In addition, the BSS is justified in its own right by the need to obtain data on behavioural trends among target populations. The data will allow the National AIDS Control Program (NACP) and other actors to follow the evolution of the epidemic and to plan their prevention activities accordingly. Monitoring the HIV epidemic and assessing the impact of HIV prevention interventions is a complex and multi-faceted process. HIV sentinel surveillance, the traditional cornerstone of a country's HIV monitoring efforts, becomes less useful as an epidemic matures. This is because HIV prevalence changes very slowly in response to behavioral changes in populations due to the chronic nature of HIV infection. Thus, HIV surveillance data cannot indicate whether prevention interventions are having their desired short-term effect of changing behaviors. Repeated behavioral surveys, on the other hand, can capture trends in behavioral change that lead to reduced HIV infection, such as fewer sexual partners and increased condom use among non-regular partners. The Tropical Disease Research Centre (TDRC) implemented the surveys with technical assistance from FHI's IMPACT project and laboratory back up from the Institute of Tropical Medicine (ITM) in Antwerp, Belgium. This report presents the results of the first round of behavioural surveillance and the baseline data on STD prevalence in female sex workers. Objectives
List of Abbreviations
Executed by: Administered by: With technical assistance from: Funded By: FHI implements the USAID IMPACT Project in partnership with the Institute of Tropical Medicine w Management Sciences for Health w Population Services International w Program for Appropriate Technology in Health w and the University of North Carolina at Chapel Hill. This work was supported (in part) by the United States Agency for International Development (USAID) as part of Family Health International's (FHI) Implementing AIDS Prevention and Care (IMPACT) Project (Cooperative Agreement HRN-A-00-97-0017-00) and does not necessarily reflect the views of USAID or FHI. |
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