Education, substance use, and HIV risk among orphaned adolescents in Eastern Zimbabwe

There is a growing interest in education as a means to reduce HIV infection in vulnerable children in sub-Saharan Africa; however, the mechanisms by which education reduces HIV infection remain uncertain. Substance use has been associated with high-risk sexual behaviour and could lie on the causal pathway between education and HIV risk. Therefore, we used multivariable regression to measure associations between: (i) orphanhood and substance use (alcohol, recreational drugs, and smoking), (ii) substance use and sexual risk behaviours, and (iii) school enrolment and substance use, in adolescents aged 15-19 years, in Eastern Zimbabwe. We found substance use to be low overall (6.4%, 3.2%, and 0.9% of males reported alcohol, drug, and cigarette use; <1% of females reported any substance use), but was more common in male maternal and double orphans than non-orphans. Substance use was positively associated with early sexual debut, number of sexual partners, and engaging in transactional sex, while school enrolment was associated with lower substance use in males. We conclude that education may reduce sexual risk behaviours and HIV infection rates among male adolescents in sub-Saharan Africa, in part, by reducing substance abuse.

'Kusvika taparadzaniswa nerufu' (Until death do us part)

A cross-sectional study of 7 667 non-virgins between 15 and 54 years of age was carried out to assess the protective effect of marriage against HIV acquisition in a rural population in Zimbabwe, whilst taking into account gender-differentials in risk factors for seroconversion. Persons in stable first marriages and long-term consensual cohabiting unions had higher odds of HIV infection than never-married people but a lower risk than those who had been divorced or widowed, even after adjusting for known confounders and significant risk factors for infection. Partner-related risk factors appear to play a more pivotal role in determining HIV prevalence in females than for males, for whom personal sexual behaviour risk factors are more dominant.

Evidence for a contribution of the community response to HIV decline in eastern Zimbabwe?

Membership of indigenous local community groups was protective against HIV for women, but not for men, in eastern Zimbabwe during the period of greatest risk reduction (1999–2004). We use four rounds of data from a population cohort to investigate: (1) the effects of membership of multiple community groups during this period; (2) the effects of group membership in the following five years; and (3) the effects of characteristics of groups hypothesised to determine their effect on HIV risk. HIV incidence from 1998 to 2003 was 1.18% (95% CI: 0.78–1.79%), 0.48% (0.20–1.16%) and 1.13% (0.57–2.27%), in women participating in one, two and three or more community groups at baseline versus 2.19% (1.75–2.75%) in other women. In 2003–2005, 36.5% (versus 43% in 1998–2000) of women were members of community groups, 50% and 56% of which discussed HIV prevention and met with other groups, respectively; the corresponding figures for men were 24% (versus 28% in 1998–2000), 51% and 58%. From 2003 to 2008, prior membership of community groups was no longer protective against HIV for women (1.13% versus 1.29%, aIRR = 1.25;p = 0.23). However, membership of groups that provided social spaces for dialogue about HIV prevention (0.62% versus 1.01%, aIRR = 0.54; p = 0.28) and groups that interacted with other groups (0.65% versus 1.01%, aIRR = 0.51; p = 0.19) showed non-significant protective effects. For women, membership of a group with external sponsorship showed a non-significant increase in HIV risk compared to membership of unsponsored groups (adjusted odds ratio = 1.63, p = 0.48). Between 2003 and 2008, membership of community groups showed a non-significant tendency towards higher HIV risk for men (1.47% versus 0.94%, p = 0.23). Community responses contributed to HIV decline in eastern Zimbabwe. Sensitive engagement and support for local groups (including non-AIDS groups) to encourage dialogue on positive local responses to HIV and to challenge harmful social norms and incorrect information could enhance HIV prevention.

In what ways do communities support optimal antiretroviral treatment in Zimbabwe?

Little research has been conducted on how pre-existing indigenous community resources, especially social networks, affect the success of externally imposed HIV interventions. Antiretroviral treatment (ART), an externally initiated biomedical intervention, is being rolled out across sub-Saharan Africa. Understanding the ways in which community networks are working to facilitate optimal ART access and adherence will enable policymakers to better engage with and bolster these pre-existing resources. We conducted 67 interviews and eight focus group discussions with 127 people from three key population groups in Manicaland, eastern Zimbabwe: healthcare workers, adults on ART and carers of children on ART. We also observed over 100 h of HIV treatment sites at local clinics and hospitals. Our research sought to determine how indigenous resources were enabling people to achieve optimal ART access and adherence. We analysed data transcripts using thematic network technique, coding references to supportive community networks that enable local people to achieve ART access and adherence. People on ART or carers of children on ART in Zimbabwe report drawing support from a variety of social networks that enable them to overcome many obstacles to adherence. Key support networks include: HIV groups; food and income support networks; home-based care, church and women's groups; family networks; and relationships with healthcare providers. More attention to the community context in which HIV initiatives occur will help ensure that interventions work with and benefit from pre-existing social capital.

Challenges faced by elderly guardians in sustaining the adherence to antiretroviral therapy in HIV-infected children in Zimbabwe

Grandparents throughout sub-Saharan Africa have shown immense courage and fortitude in providing care and support for AIDS-affected children. However, growing old comes with a number of challenges which can compromise the quality of care and support they are able to provide, particularly for children infected by HIV and enrolled on antiretroviral therapy (ART) programmes. For ART to be effective, and for infected children not to develop drug-resistance, a complex treatment regimen must be followed. Drawing on the perspectives of 25 nurses and eight grandparents of HIV-infected children in Manicaland, eastern Zimbabwe, we explore some of the challenges faced by grandparents in sustaining children's adherence to ART. These challenges, serving as barriers to paediatric ART, are poverty, immobility, deteriorating memory and poor comprehension of complex treatments. Although older HIV-infected children were found to play an active role in sustaining the adherence to their programme of treatment by contributing to income and food generating activities and reminding their guardians about check-ups and drug administration, such contribution was not available from younger children. There is therefore an urgent need to develop ART services that both take into consideration the needs of elderly guardians and acknowledge and enhance the agency of older children as active and responsible contributors to ART adherence.

Sources of motivation and frustration among healthcare workers administering antiretroviral treatment for HIV in rural Zimbabwe

The roll-out of accessible and affordable antiretroviral (ARV) drugs for people living with HIV in low-income countries is drastically changing the nature of HIV-related healthcare. The Zimbabwean Ministry of Health has renewed efforts to make antiretroviral treatment (ART) for HIV free and publically available across the country. This paper describes the findings from a multi-method qualitative study including interviews and a focus group with healthcare workers (mostly nurses), totalling 25 participants, and field notes from over 100 hours of ethnographic observation in three rural Zimbabwean health centres. These health centres began providing free ARV drugs to HIV-positive people over one year prior to the research period. We examined sources of motivation and frustration among nurses administering ART in these resource-poor health centres. The findings suggest that healthcare workers administering ART in challenging circumstances are adept at drawing strength from the dramatic physical and emotional recoveries made possible by ART and from their personal memories of the suffering caused by HIV/AIDS among close friends or family. However, healthcare staff grappled with extreme resource shortages, which led to exhaustion and frustration. Surprisingly, only one year into ART provision, healthcare workers did not reference the professional challenges of their HIV work before ART became available, suggesting that medical breakthroughs such as ART rapidly come to be seen as a standard element of nursing. Our findings provide a basis for optimism that medical breakthroughs such as ART can reinvigorate healthcare workers in the short term. However, we caution that the daily challenges of nursing in poor environments, especially administering an ongoing and resource-intensive regime such as ART, must be addressed to enable nurses to continue delivering high-quality ART in sub-Saharan Africa.

Measuring trends in age at first sex and age at marriage in Manicaland, Zimbabwe

OBJECTIVE

To identify reporting biases and to determine the influence of inconsistent reporting on observed trends in the timing of age at first sex and age at marriage.

METHODS

Longitudinal data from three rounds of a population-based cohort in eastern Zimbabwe were analysed. Reports of age at first sex and age at marriage from 6837 individuals attending multiple rounds were classified according to consistency. Survival analysis was used to identify trends in the timing of first sex and marriage.

RESULTS

In this population, women initiate sex and enter marriage at younger ages than men but spend much less time between first sex and marriage. Among those surveyed between 1998 and 2005, median ages at first sex and first marriage were 18.5 years and 21.4 years for men and 18.2 years and 18.5 years, respectively, for women aged 15-54 years. High levels of reports of both age at first sex and age at marriage among those attending multiple surveys were found to be unreliable. Excluding reports identified as unreliable from these analyses did not alter the observed trends in either age at first sex or age at marriage. Tracing birth cohorts as they aged revealed reporting biases, particularly among the youngest cohorts. Comparisons by birth cohorts, which span a period of >40 years, indicate that median age at first sex has remained constant over time for women but has declined gradually for men.

CONCLUSIONS

Although many reports of age at first sex and age at marriage were found to be unreliable, inclusion of such reports did not result in artificial generation or suppression of trends.

Role of widows in the heterosexual transmission of HIV in Manicaland, Zimbabwe, 1998-2003

BACKGROUND

AIDS is the main driver of young widowhood in southern Africa.

METHODS

The demographic characteristics of widows, their reported risk behaviours and the prevalence of HIV were examined by analysing a longitudinal population-based cohort of men and women aged 15-54 years in Manicaland, eastern Zimbabwe. The results from statistical analyses were used to construct a mathematical simulation model with the aim of estimating the contribution of widow behaviour to heterosexual HIV transmission.

RESULTS

413 (11.4%) sexually experienced women and 31 (1.2%) sexually experienced men were reported to be widowed at the time of follow-up. The prevalence of HIV was exceptionally high among both widows (61%) and widowers (male widows) (54%). Widows were more likely to have high rates of partner change and engage in a pattern of transactional sex than married women. Widowers took partners who were a median of 10 years younger than themselves. Mathematical model simulations of different scenarios of sexual behaviour of widows suggested that the sexual activity of widow(er)s may underlie 8-17% of new HIV infections over a 20-year period.

CONCLUSIONS

This combined statistical analysis and model simulation suggest that widowhood plays an important role in the transmission of HIV in this rural Zimbabwean population. High-risk partnerships may be formed when widowed men and women reconnect to the sexual network.

Discrepancies between UN models and DHS survey estimates of maternal orphan prevalence: insights from analyses of survey data from Zimbabwe

OBJECTIVES

Model-based estimates of maternal (but not paternal) orphanhood are higher than those based on data from demographic and health surveys (DHS). We investigate the consistency of reporting of parental survival status in data from Manicaland, Zimbabwe.

METHODS

We compared estimates of paternal and maternal orphan prevalence in three rounds of a prospective household census in Manicaland (1998-2005) with estimates from DHS surveys and UNAIDS model projections. We investigated the consistency of reporting of parental survival status across the three rounds and compared estimates of adult mortality from the orphan data with direct estimates from concurrent follow-up of a general population cohort. Qualitative data were collected on possible reasons for misreporting.

RESULTS

Paternal and maternal orphan prevalence is increasing in Zimbabwe. Mothers reported as deceased in round 1 of the Manicaland survey were more likely than fathers to be reported as alive in rounds 2 or 3 (33.3% vs 13.4%). This pattern was most apparent among younger children. The qualitative findings suggest that foster parents sometimes claim adopted children as their natural children.

CONCLUSIONS

These results are consistent with misreporting of foster parents as natural parents. This appears to be particularly common among foster mothers and could partly explain the discrepancy between mathematical model and DHS estimates of maternal orphanhood.

Informal confidential voting interview methods and temporal changes in reported sexual risk behaviour for HIV transmission in sub-Saharan Africa

OBJECTIVES

Reliable data on sexual behaviour trends are needed to evaluate HIV interventions in sub-Saharan Africa but are difficult to obtain due inter alia to social desirability bias. The objective of this paper is to assess whether the use of informal confidential voting interviews (ICVI) was associated with greater reporting of socially proscribed behavioural risk factors for HIV infection than were conventional interviewing methods.

METHODS

Comparison of changes in reports of risk behaviours for HIV infection in ICVI versus face to face interviews (FTFIs) between the first two rounds of a large scale, longitudinal, population based survey in Manicaland, Zimbabwe. Examination of factors that could contribute to observed changes in the effect of ICVI, including temporal changes in response error and social desirability, and factors affecting statistical power to detect differences between methods-that is, reductions in the prevalence of risk behaviours and sample size.

RESULTS

Enhanced reporting of HIV associated risk behaviours in ICVI interviews was not so apparent in the second round as in the first round of the survey, particularly for less frequently reported behaviours. Levels of reported HIV associated risk behaviour and sample sizes both declined between the two survey rounds. The level of response error was higher in ICVI interviews than in FTFI interviews but did not alter over time.

CONCLUSION

ICVI interviews can reduce social desirability bias in data on HIV associated risk behaviours. The extent and direction of change in net reduction in bias over time remains uncertain and will depend on local circumstances.