NYU Master's Program in Global Public Health Capstone Program
UNDERSTANDING THE CONTEXT OF HIV RISK IN ZAMBIA
A Study of Mongu, Senanga, and Kaoma Districts in the Western Province
Rebecca Adeskavitz, MPADonovan Jones, MAMoneesha Kamani, MSc, MSErin Murphy, MMS, PA-CJanet Vessotskie, MS, PhD
Report May 2010
HIV and AIDS IN ZAMBIA
The 2007 Zambia Demographic Health Survey revealed that HIV prevalence rates in the general population have dropped from 16% to 14%
However… Young women have been especially hard hit; 16% of women aged 20-24 are infected compared to just 4% of men in the same age group
3 out of 9 provinces have a rising HIV prevalence, including the Western Province
Identify problem
The cause of these new infections is not yet known, though many point to cultural practices such as:
• Sexual Cleansing• Widow Inheritance• Dry Sex• Polygamy• Female Initiation• Male Circumcision
RESEARCH QUESTIONS
DefineResearchQuestions
The following research questions were agreed:
NYU partnered with Concern Worldwide Zambia in collaboration with ARHA, DAPP, DHMTs and DATFs to undertake a qualitative exploratory study in 2010
•What are the sexual practices in Zambia’s Western Province that are putting people at risk for HIV?
• What are the contextual factors that influence the continuation of these practices?
Concern Worldwide began working in Zambia in 2002
- HIV Prevention, Livelihood Protection and Emergency Response
STUDY DESIGN Definethe
Problem
Design Study
Study DesignQualitative study utilizing rapid assessment techniques
Study SettingMongu, Senanga & Kaoma Districts in Western Province
Methods• Key Informant Interviews• In-depth Interviews• Focus Group Discussions
IndividualFactors
Structural Factors
Social Factors
HIVTransmission
Dynamics
HIVIncidence
Social Capital
Cultural Context
Social NetworksStructural Violence & Discrimination
Policy Environment
Legal Structures
Behavior
Individual Characteristics
Socioeconomic Position
POVERTYSource: Adapted from Poundstone, Strathdee & Celentano, 2004
THEORETICAL FRAMEWORK
DATA COLLECTION
DataCollection
Mongu Senanga Kaoma
Focus Group Discussions
6 2 2
No. of FG Participants
46 13 14
In-depth Interviews
8 0 0
Key Informant Interviews
10 1 7
Total Participants 54 14 21
Data collection took place over a two-week period
Focus Group Participants
47 Average Age (years)
54 % Male
46 % Female
48 % Married
30 % of participants who reached secondary level education
Interviews •NGO leaders• Government officials• Local/tribal leaders• Traditional healers• Church leaders• Community Health Workers
A tree provides shade for a focus group in Itufa, Senanga District.
Analysis
ANALYSIS
Secondary DataZambian DHSOther studies
Focus Group Discussions
In-depth and Key Informant
Interviews
Triangulation
RESULTS
What are the factors driving the epidemic?In-depth analysis of interview and focus group transcripts revealed a number of social and structural factors that act as both barriers and facilitators for HIV risk behaviors.
5 meaningful themes emerged:
Traditional Norms & Practices
Gender, Power & Inequality
Social Factors
Prevention & Disconnected Messages
Infrastructure & Service Delivery
Major Findings - Learning:• Cultural norms and practices are contributing to the spread of HIV in the Western Province
• Some traditional practices have a positive effect and are helping to protect against HIV transmission
• Harmful practices are slowly changing in response to HIV
It is a symbol in our culture that if you have more that one wife, you must be a very powerful person
or a very rich person who is able to look after those wives
—Senior Government Official, Mongu
TRADITIONAL NORMS & PRACTICES
Major Findings - Learning:
• Women are socially and economically disadvantaged in the Western Province
• Gender inequality is manifested in sexual coercion, reduced condom negotiating power and partnering with older men, all practices that heighten risk for HIV
• Transactional sex is widespread
…Wearing a condom is regarded as taboo even for family planning. Women are unable to
negotiate condom use even when the partners are HIV positive
—Grace Hamukwala, Mongu District HIV Manager, Concern Worldwide
GENDER, POWER & INEQUALITY
…It is normal for a man to have multiple sexual relationships. The community will not say anything.
It is just normal that you have a girlfriend apart from your wife - these cultural issues are still being
highly practiced in rural areas
—Brian Kayongo, Executive Director, Adolescent Reproductive Health Advocates
Major Findings - Learning:
• Multiple partnerships are generally accepted in Zambia (more for men than women) and are practiced widely in the Western Province
• Widespread alcohol use contributes to risky behavior, particularly lack of condom use
SOCIAL FACTORS
Major Findings - Learning:
• Prevention messages are coming from all levels of society and are often contradictory
• Tension exists between abstinence-only messages and messages promoting condom use
• There has been a lack of leadership on a number of issues
PREVENTION & DISCONNECTED MESSAGES
Apart from coming out on radio supporting HIV and AIDS programs they have not been proactive…if the
King stands and says no one will marry a 11 year girl no one will do that because there is so much
respect for the King
—Brian Kayongo, Executive Director, Adolescent Reproductive Health Advocates
In terms of accessibility, most of our rural areas do not have access to condoms. They are only
concentrated in the township area.
—Senior Health Official, Mongu
Major Findings - Learning:
• Condom access is inconsistent and misconceptions are pervasive
• HIV Testing services have increased, but gaps still exist
• Community members report adequate ART coverage, community leaders report rural gaps
• Lack of communication / coordination between NGOs, Church leaders and Local Government departments
INFRASTRUCTURE & SERVICE DELIVERY
RiskLow
Medium
High
Low
Medium High
Female initiation
Polygamy
Traditional leader influence
Religious influence
MigrationVenues for sex
Stigma
HIV Risk Factors in the Western Province
Gender inequalityDry sex
Multiple sexual partnersSex workers
Rural-urban gap: service & practices
Poverty
School prevention programs
Sexual cleansing
Multiple circumcisions with one knife
Widow inheritance Media influence
Traditional medicine
Misconceptions of condoms
Alcohol abuse
Early sexual debutInability to
negotiate condom use
Lack of government support
Limited access to HIV testing
Lack of access to ART
Lack of access to condoms
MSM
Lack of family dialog on HIV
RECOMMENDATIONS
INDIVIDUAL
STRUCTURAL
SOCIAL
Increase HIV education efforts, targeting misconceptions and considering the local context
Introduce programs that address gender norms and empower women
Increase commitment and cooperation among leaders at all levels
Increase condom distribution partnered with education and directed at HIV “hot spots”
Expand reach of HIV testing and treatment services
• Increasing involvement of Traditional Leaders
• Increasing sensitization of young women in rural areas on HIV risk reduction
• Expanding HIV mainstreaming responses through existing community structures – community action teams (CATs) using the ‘community conversation’ methodology
• S/BCC through HH approach – focusing on: - VCT information
- service referral - increasing male involvement
- reducing stigma and discrimination
• Establishing Western Province NGO Forum for advocacy to national level
PROGRAMME RESPONSES
to the people of Zambia and all participants who agreed to take part in this study
We are also grateful to the entire Concern Zambia staff for their support.
We would particularly like to thank Maurice Sadlier, Friday Mwamba, Nalisa Mufuzi, Francis Wakumelo,
Grace Hamukwala and Edna Kalaluka
A special thank you to Dr. Kristin Bright of New York University
N’itumezi (thank you)