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A surprising prevention success: Why did the HIV epidemic decline in Zimbabwe
Daniel T. Halperin, Owen Mugurungi, Timothy B. Hallett, Backson Muchini, Bruce Campbell, Tapuwa Magure, Clemens Benedikt, Simon Gregson, PLoS

February 08, 2011

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While dramatic gains in the availability of antiretroviral medications in developing countries have been achieved, there is growing consensus that, unless prevention efforts can be made more effective, there will ultimately be no victory in the fight against HIV/AIDS. Maintaining tens of millions of people on treatment throughout their lifetimes will not be sustainable or affordable, particularly as drug resistance may increasingly result in the need for much more expensive second and third line medications. Although there have been promising breakthroughs in a few other areas, notably male circumcision and prevention of mother-to-child transmission (PMTCT), it is widely recognized that behavior change must remain the core of prevention efforts.

While the often cited prevention success stories of Thailand and Uganda are inspiring and informative, some of the specific socio-cultural, historical, and other factors in the southern African region-now the global epicenter of the HIV pandemic-are distinctive. In these ''hyper-endemic'' settings, where adult HIV prevalence ranges from 12% to 26% , HIV transmission is highly generalized, whereas Thailand's epidemic was much more concentrated. There, HIV transmission was driven mainly by brothelbased sex work-enabling the aggressive ''100 percent condom'' programs to be feasible, enforceable, and effective. The unprecedented HIV decline and associated behavior change in Uganda, mainly involving large reductions in multiple sexual partnerships, occurred some 20 years ago and under rather different contextual and programmatic circumstances.

Synthesis of Data


HIV prevalence data from national antenatal clinic surveillance and the household-based 2005/6 Demographic and Health Survey (DHS) were used to fit a mathematical model to estimate trends in HIV incidence and AIDS deaths in Zimbabwe (Figure 1A). Data from the DHS and other longitudinal surveys were used to examine the possible contributions of changes in sexual behavior to reductions in HIV infection. Published data from focus group discussions with 90 adult men and 110 women in diverse urban and rural sites and several dozen in-depth key informant interviews as well as an extensive historical mapping of prevention programs, were examined in assessing the contributions of different contextual and programmatic factors to observed changes in behavior. Finally, DHS data on various potential proximal and contextual determinants of behavior change for Zimbabwe were compared with similar data for seven other southern African countries to identify distinctive patterns that might help to explain the earlier and faster HIV decline observed in Zimbabwe (Figures 2, S1).

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