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)