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Lessons in HIV prevention
February 11, 2011
African countries struggling
to contain HIV epidemics can learn a thing or two about HIV prevention
from Zimbabwe, say the authors of a new study which found that a
reduction in sexual partners drove a decrease in new HIV infections
Zimbabwe's HIV prevalence
fell by 13 percent between 1997 and 2007, a decline too steep to
be attributed solely to HIV's natural progression and a hint that
something else was forming a crucial part of the HIV reduction equation,
said lead author and Harvard University Public Health lecturer Daniel
"The modelling showed
it couldn't just be the natural curve [of the epidemic]; the decline
was too dramatic," he told IRIN/PlusNews. "The modelling
suggested it was also due to behaviour change and behavioural data
also suggested a change, but what was missing was the all important
According to Halperin,
Zimbabwe's success story points to the power of social change and
the need for more detailed analyses of HIV success stories in Africa.
He compared it to the role of partner reduction in the fight against
HIV in Uganda, which promoted a reduction in multiple partnerships
as the key focus of its HIV prevention campaigns in the late 1980s
and early 1990s.
While many countries
in sub-Saharan Africa, such as Ethiopia and Kenya, have seen recent
reductions in HIV prevalence, it remains difficult to understand
exactly what has driven these drops.
pay and fear
To find the reasons behind
Zimbabwe's steep decline, researchers drew on almost a decade of
HIV data, including mathematical models, large-scale HIV prevention
trials and national surveys. Researchers supplemented this research
with in-depth expert interviews and focus group discussions with
200 participants nationwide.
From 1990 to 2000, AIDS-related
deaths rose by 30 percent in Zimbabwe, and according to researchers,
focus groups revealed that this spike in AIDS-related mortality
scared many into behaviour change.
"In the focus groups,
men said things like: 'Oh I used to have a lot of girl friends.
I used to have lots of fun, then my uncle died of AIDS',"
Halperin said. "A lot of these men said, 'I can't leave my
According to the paper,
focus group discussions also reported that societal norms shifted
during this time and that increasing stigma was attached to factors
associated with HIV risk such as paying for sex, having sexually
transmitted infections (STIs) and multiple concurrent partnerships
Data from an HIV research
site in Zimbabwe's Manicaland province showed that men who reported
having MCPs fell by 40 percent between about 1998 and 2003 - roughly
the same time period in which the number of new HIV infections was
falling rapidly and salaries in the country fell by about 90 percent.
While men in focus groups
said this decline in earnings made them less able to afford to pay
for sex or sustain multiple sexual relationships, Halperin cautioned
that economics probably only played a secondary role in reducing
HIV, as new infections had began to decrease years before the effects
of the recession were widely felt in about 2003.
bigger picture for Africa
Halperin noted that when
compared to other countries with well-funded HIV prevention programmes
- such as Botswana - which have not charted such large gains in
HIV prevention, Zimbabwe's success story may highlight that grass
roots, social change is not necessarily a result of big spending.
"I think the donor-funded
HIV programmes were probably useful in bringing down HIV prevalence
but I think this shows you just can't pump money into a country,
that things are only going to turn around once the communities get
mobilized," he said. "[In Zimbabwe] the community sort
of 'got it'; there was a change in norms and that became a part
of popular culture."
"Many guys in focus
groups said that if you got STIs in the early 1990s, you were called
a 'hero', then universally around 1999, you never heard that again.
Something happened in societal norms and I don't think there was
some donor-funded programme that told people that STIs were shameful,"
"I think a lot of
credit goes to the Zimbabwean people themselves."
As more success stories
emerge, Halperin said that more detailed analyses that looked at
behaviour; epidemiology and programme coverage would be needed to
explain successes, and failures.
"MCPs were the answer
here but they may not be the answer everywhere; we need to do this
kind of study in different countries, different situations,"
he said. "The key is to triangulate HIV data with behaviour
data, but we also need qualitative data... We need to ask people
very specifically: 'What's going on in your community'."
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